Beruflich Dokumente
Kultur Dokumente
Radiology
Shahid Hussain
MA, MB, BChir, MRCP, FRCR
Consultant Radiologist
Heart of England NHS Foundation Trust, Birmingham, UK
MANSON
PUBLISHING
Dedications
S.H. To my mum
S.L. To my mum and dad, my wife Darine and baby Danny
A.H. - For my parents, my wife Kirstie and my sons Oliver, Tristan and Seb
Contents
Preface
Contributors
Abbreviations
General Introduction
11
71
147
205
289
331
Further Reading
343
344
General Index
346
Preface
As in all specialties, learning in radiology is a lifelong process. Yet the rate of learning is undoubtedly highest in the
trainee years, when there is a vast amount of information
to assimilate. There are many excellent, comprehensive
radiology texts available to facilitate this, yet learning for
most of us is a more haphazard process than reading such
a text from cover to cover. More commonly, we learn
initially unrelated pieces of information from multiple
sources and these gradually join together like the pieces of
a jigsaw, using the comprehensive textbook as a reference
along the way. The practical aspects of image recognition
and formulating a differential diagnosis become ever more
important, especially as postgraduate exams loom! Again,
there are already excellent radiology atlases and text-based
differential diagnosis guides that become standard reading
for the trainee.
Our aim in writing this text was to bring together the
images with the differential diagnosis information, adding
some practical advice along with it. Such a book cannot be
comprehensive without becoming another large general
text. Instead, we have tried to compile a selection of cases
covering many aspects of radiology, particularly the types
used in radiology vivas. These include the so-called Aunt
Minnie cases, where a classic image becomes simple
pattern recognition, and also the cases where findings need
to be pieced together along with the clinical history to
formulate a differential diagnosis. This selection of cases
will thus provide image and factual learning material for a
broad sample of disorders that will intertwine with material
learnt elsewhere. The format is intended to help the trainee
starting out with practical issues such as how to approach
films and the vocabulary to use; the trainee approaching
exams with a means of self-testing and rehearsing cases;
and also the nonradiologist to practise some more
challenging material. The selection of cases is hopefully
broad enough to provide an introduction to some exam
favourites for the beginner, but also more testing cases for
those in later stages of training.
In order for the candidate to test him- or herself, we
have presented each case as an image (or set of images)
together with the pertinent clinical details. Over the page
is a description of the images as would be given to an
examiner in a long case or a viva situation. This is perhaps
Contributors
Professor Iain Lyburn, Consultant Radiologist, Gloucestershire Hospital NHS Foundation Trust for the breast
imaging chapter.
Dr Bernd Wittkop, Consultant Radiologist, Worcestershire Acute Hospitals Trust for the nuclear medicine cases.
For the contribution of images: Dr Anne Gregan,
Consultant Radiologist, Dudley Group of Hospitals NHS
Trust; Dr Peter Oliver, Consultant Radiologist, Dudley
Group of Hospitals NHS Trust; Dr Ruth Shave,
Consultant Radiologist, Dudley Group of Hospitals NHS
Trust; Dr Katharine Foster, Consultant Radiologist,
Birmingham Childrens Hospital NHS Foundation Trust;
Dr Umesh Udeshi, Consultant Radiologist, Worcestershire
Acute Hospitals Trust; Dr Dee Dawkins, Consultant
Radiologist, Sandwell & West Birmingham Hospitals NHS
Trust; Dr Hong Gap-Teo, Consultant Radiologist,
Abbreviations
ABC
ABPA
AD
ADC
ADEM
ADPKD
AF
AIDS
ANA
AP
ASD
AVM
AVN
AXR
BP
CAD
CAM
CC
CDH
CF
CFA
CMV
CNS
COP
CP
CRM
CSF
CT
CVA
CWP
CXR
DCIS
DWI
EAA
ECG
ECMO
ENT
ERCP
Abbreviations
GI
gastrointestinal
HIV
human immunodeficiency virus
HMD
hyaline membrane disease
HPOA
hypertrophic pulmonary osteoarthropathy
HRCT
high-resolution computed tomography
HRT
hormone replacement therapy
HSP
HenochSchnlein purpura
HSV
herpes simplex virus
HU
Hounsfield units
IAC
internal auditory canal
IDC
invasive ductal carcinoma
ILC
invasive lobular carcinoma
IPF
idiopathic pulmonary fibrosis
ITU
intensive treatment unit
IV
intravenous
IVC
inferior vena cava
IVU
intravenous urogram
LP
lumbar puncture
MCA
middle cerebral artery
MCUG
micturating cystourethrogram
MEN
multiple endocrine neoplasia
MIBG
meta-iodobenzylguanidine
MIP
maximum intensity projection
MISME syndrome
multiple inherited schwannoma,
meningioma and ependymoma
MLO
mediolateral oblique
MRA
magnetic resonance angiography
MRCP
magnetic resonance
cholangiopancreatography
MRI
magnetic resonance imaging
MS
multiple sclerosis
MSK
musculoskeletal
NAI
non accidental injury
NEC
necrotizing enterocolitis
NF1
neurofibromatosis type 1
NG
nasogastric
NOS
not otherwise specified
NSAIDs
nonsteroidal anti-inflammatory drugs
OA
osteoarthritis
OKC
odontogenic keratocyst
OPG
PA
PCA
PCP
PD
PDA
PET
PICA
PIE
PMF
PNET
PSC
PVL
RA
RTA
SACE
SAH
SBC
SI
SLE
SMV
STIR
SUFE
SVC
TB
TCC
TE
TIA
TIPS
TME
TNM
TOF
UBOs
UC
US
UTI
VAD
VATS
VHL
VSD
orthopantomogram
posteroanterior
posterior cerebral artery
Pneumo cystis carinii pneumonia
proton density
patent ductus arteriosus
positron emission tomography
posterior inferior cerebellar artery
pulmonary interstitial emphysema
progressive massive fibrosis
primitive neuroectodermal tumour
primary sclerosing cholangitis
periventricular leukomalacia
rheumatoid arthritis
renal tubular acidosis
serum angiotensin converting enzyme
subarachnoid haemorrhage
simple bone cyst
superioinferior
systemic lupus erythematosus
superior mesenteric vein
short tau inversion recovery
slipped upper femoral epiphysis
superior vena cava
tuberculosis
transitional cell carcinoma
time to echo
transient ischaemic attack
transjugular intrahepatic portosystemic
shunt
total mesorectal excision
tumournodemetastases staging
tracheoesophageal fistula
unidentified bright objects
ulcerative colitis
ultrasound
urinary tract infection
vacuum assisted device
video assisted thorascopic surgery
von HippelLindau syndrome
ventricular septal defect
GENERAL
INTRODUCTION
This book has been written primarily for senior radiology
trainees preparing for final radiology exams and in particular
for trainees studying for the Fellowship of the Royal
College of Radiology. With this in mind, the cases
presented herewith have been presented in the exact
manner that the cases are presented in the Royal College
of Radiology FRCR 2B exam. In the exam, long cases and
viva cases are presented with a very minimal but highly
relevant history and the required response is expected to
be presented in a particular way. This format of reporting1
involves giving a Description/Interpretation of the images;
Diagnosis; Differential Diagnosis; and advice on Further
Management. We have laid out the answers here in exactly
this manner and have included a Discussion to give indepth further information about each condition which will
enable the student to answer any questions directed to him
or her in the viva situation. By following the RCR exam
format, the candidate should be ideally prepared for this
exam and for the future as a Consultant Radiologist.
FILM TECHNIQUE
Whatever the imaging modality, the radiologist interprets
images using all the information and clues available, to
produce a differential diagnosis and/or advise on further
investigation and management. Above all else, this must be
done in a SAFE manner, and this often requires one to be
systematic in approach. Secondly, this process must be done
in a SENSIBLE manner it is easy to quote endless lists of
differential diagnoses but if these are not refined for each
individual case, the radiologists input is of little value. The
following discussion concentrates in particular on
performing these tasks in the examination viva scenario.
However, much of the advice is applicable to everyday
practice too, in particular the emphasis on a safe and
sensible approach.
TYPES OF FILM
The types of film one may encounter in an exam/viva are as
follows:
General Introduction
The discussion
Further management
Description
Relevant positive and negative radiological findings in a
systematic manner, summarizing the findings at the end of
the description.
Diagnosis
Try to identify relevant information in the history/patient
data/radiological findings/other investigations which
narrows the differential list down.
Differential diagnosis
Give a list of differentials for the findings.
General Introduction
Reference
1. Royal College of Radiology Guidance on Format of
Reporting Session Reports for FRCR Part 2B;
http://www.rcr.ac.uk/content.aspx?PageID=713
SUMMARY
Use the same structured format for reporting radiology cases, which
consists of:
DESCRIPTION
Give your OBSERVATIONS on the films including relevant positive
and negative findings and then give your INTERPRETATION of
these findings.
DIAGNOSIS
Give the best fit diagnosis for the image findings.
DIFFERENTIAL DIAGNOSIS
Give a limited number of possible differential diagnoses for the image
findings.
FURTHER MANAGEMENT
Give suggestions for relevant further investigations and immediate
management which need to be undertaken.
Chapter 1
CHEST IMAGING
Lines
Comment on the additional lines that you can see on the
film these may include ECG leads, oxygen tubing, NG
tube, central venous catheters, chest drain and
pacemakers/wires. These are important, first because you
should assess that they are in the correct place and that
their insertion has had no complications, e.g. ensure the
NG tube is in the stomach, that there is no pneumothorax
associated with the jugular central line. Secondly,
identifying lines is important in assessing how unwell the
patient is your differential diagnosis is clearly going to be
different if the chest radiograph is from an intubated ITU
patient than if it is from an outpatient.
Lungs
First assess the chest to ensure that the general
opacification in both lungs is the same if not, then you
need to determine which is the abnormally hyper or hypo
transradiant lung and determine what the cause is.
Mastectomy is one obvious cause that must not be missed
as a history of breast cancer means the film must be
checked carefully for evidence of metastatic spread.
Once you have decided what/where the abnormality is
then describe the findings using a common vocabulary that
is understood by all and which leaves no room for
confusion. Accordingly, abnormalities can be described as:
Focal or diffuse.
Located in upper/middle/lower zones (avoids the
difficulty of assessing lobes at the outset).
Central or peripheral.
Single or multiple.
Exhibiting calcification or cavitation.
Broadly speaking lung abnormalities consist of:
Focal pulmonary lesion
You need to assess whether there are single or multiple
lesions. Is there calcification? Is there cavitation? The
differential diagnosis will depend on these patterns and
useful information that will help you to narrow down the
diagnosis can be sought from the examiner, such as a
history of pyrexia, weight loss, haemoptysis, etc.
Diffuse pulmonary opacity
First, make a distinction between alveolar (airspace) and
interstitial opacity. The former has a poorly defined, fluffy,
cottonwool-like appearance, while the latter consists of
reticular opacities, nodular opacities or a combination of
both. The differential diagnosis will often be very different,
as explained in subsequent cases in this chapter.
11
Chest Imaging
Hila
Assess the hila for position (left should be slightly higher
than the right), shape (a V-shape made by the angle of the
superior pulmonary artery and inferior pulmonary vein) and
size.
A change in the position of the hilum suggests volume
loss. Accompanying interstitial opacity suggests
fibrosis, whereas airspace opacity might suggest
atelectasis, for which there are many causes, in
particular obstructing masses.
If there is change in the hilar angle or size then this
would suggest a hilar mass such as enlarged nodes or
central tumour.
Mediastinum
Comment on the heart size is it enlarged or small? If
there is any doubt from observation alone, state that you
would like to formally measure it. Assess the mediastinal
contour, including the cardiac contour itself and the great
vessels. Ensure the trachea is central, that there is no
pneumomediastinum or pneumopericardium. Large mediastinal masses will be readily evident but check that there is
no loss of the paratracheal stripe due to smaller masses such
as lymphadenopathy.
General tips
Comparison with previous films is very useful in
everyday practice. A solitary pulmonary nodule
measuring 2 cm but not present on a film taken just a
few months ago may well be neoplastic, whereas a
stable appearance over many years makes this unlikely.
Once you have described the film and given a
differential diagnosis, only then ask for other studies
or more clinical information if it will help narrow
down the list of possibilities or aid management it
shows that you are able to make a differential list with
no clinical information and then narrow this down in
line with the clinical scenario. This is radiology in
practice!
CT THORAX
Just as for the plain radiograph, one must systematically
evaluate lungs, mediastinum, pleura, bones, peripheral soft
tissues, etc. In doing so, it is of course important to utilize
soft tissue, bone and lung windows if available. Make a
note of whether IV contrast has been given.
Pleura
Lungs
Bones
Check the ribs, looking for:
Lytic/sclerotic lesions to suggest metastases.
Fractures if present look for a pneumothorax or
other signs of trauma. Certain fractures, such as those
of the upper three ribs, suggest significant trauma and
a high index of suspicion for other injuries is required.
Rib resection from a previous thoracotomy.
Check the thoracic spine, not forgetting to pay attention
to the paravertebral soft tissues that may point to
underlying bony abnormalities. The cervical spine may be
partly seen look for a cervical rib.
Bony abnormalities around the shoulders present some
favourite cases for vivas, so dont forget to check these areas
towards the edge of the film!
Review areas
Everyone will have particular areas on certain investigations
that they forget to evaluate well. These areas vary for each
individual, but there are certain recurring patterns of missed
abnormalities on the chest radiograph. So know your own
perceptual blind spots. In general, it is useful to check:
Behind the heart to look for a hidden mass or left
lower lobe collapse.
At the lung apices is there a Pancoast tumour there?
Beneath the diaphragm is there free gas/
splenomegaly/liver lesion?
12
Mediastinum
Check for normal patency and anatomy of great vessels,
excluding aneurysm, dissection flaps, etc. Assess for
abnormal lymphadenopathy. Assess heart for size,
morphology, normal myocardial enhancement, filling
defects, etc. Modern CT scans often demonstrate the
proximal coronary arteries even without specific cardiac
gating techniques. Dont forget to follow the superior
mediastinum into the lower neck and supraclavicular
fossae.
Pleura
Small pleural nodules and plaques can be easily missed if
not specifically evaluated. Pneumothorax may well only be
evident on lung windows.
Bones
Bone windows are essential. Multiplanar reformats made
possible by multidetector CT scanners make assessment of
the spine and ribs much easier than axial images alone.
Chest Imaging
CASE 1
Cases 1, 2
1a
History
A 34-year-old Caucasian male presented
to his GP with a dry cough and
shortness of breath for 3 months. He
was otherwise fit and well.
CASE 2
2a
History
A 32-year-old Asian male presented
with productive cough, shortness of
breath and night sweats.
13
Answer 1
Chest Imaging
ANSWER 1
Observations (1a)
This chest radiograph shows bilateral reticulonodular
shadowing predominantly affecting the mid and upper
zones with sparing of the absolute apices. The nodules are
small, ~34 mm in diameter, and appear ill defined, and
form confluent airspace opacities centrally. There is hilar
enlargement more obvious on the right, and also widening
of the right paratracheal soft tissues due to
lymphadenopathy. Given the clinical details, sarcoidosis is
the most likely diagnosis.
Diagnosis
Pulmonary sarcoidosis.
Differential diagnosis
1b
Discussion
Sarcoidosis is a systemic disorder characterized by the
presence of noncaseating granulomas within several organs.
It most commonly presents in young adults in the 3rd5th
decades, and is more common in women and in black
populations. Multisystem involvement can result in uveitis,
bilateral parotid enlargement, erythema nodosum, lupus
pernio, arthralgia, heart block, cardiomyopathy and bony
changes most commonly seen in the phalanges.
Radiological features of pulmonary sarcoidosis are as
follows:
Lymphadenopathy (7080%) is characterized by
bilateral, symmetrical hilar lymph node enlargement
and paratracheal lymphadenopathy. Egg shell
calcification of the nodes (1b) is seen in ~5% of
patients. Lymphadenopathy without pulmonary
changes has a more favourable outcome. Figure 1c
shows bilateral hilar lymphadenopathy with no
parenchymal disease.
The most common form of parenchymal change is
multiple small pulmonary nodules within the mid and
upper zones of both lungs the distribution described
in this case is classical. Presentation with larger
nodules measuring 15 cm, possibly with central
cavitation and calcification, account for ~5% of cases.
Airspace opacities are seen in 210%.
End stage disease results in upper zone fibrosis with
associated traction bronchiectasis.
14
1c
Answers 1, 2
Chest Imaging
Practical tips
Whenever there is evidence of adenopathy and
abnormal pulmonary opacities, always consider
sarcoidosis in the differential diagnosis.
The features described above are largely the classical
appearances. However, sarcoid can have almost any
appearance on a chest radiograph, so be wary of
categorically dismissing the diagnosis when the chest
film shows abnormal pulmonary parenchyma.
Conversely, it will often be a reasonable condition to
list in the differential diagnoses because of its protean
appearances.
HRCT is very useful for further evaluation. Look for
nodularity along the bronchovascular bundles,
interlobular septae and pleura. Pleural nodularity due
to subpleural lymphatic spread is often easiest to
appreciate at the interlobar fissures where multiple
layers of pleura make the changes more apparent.
1d
Further management
Gallium scanning is now rarely used in diagnosing the
condition and in assessing disease activity. Recognized
patterns of activity include the lamda sign
(paratracheal and bilateral hilar uptake) and the
panda sign (uptake in the parotid, salivary and
lacrimal glands gives appearance of a panda face).
ANSWER 2
Observations (2a)
Discussion
Diagnosis
Primary tuberculosis (TB).
Differential diagnosis
For consolidation and lymphadenopathy:
TB.
Sarcoid.
Lymphoma.
Other infective organisms: histoplasmosis,
mycoplasma, varicella.
(co nt.)
15
Answer 2
Chest Imaging
Complications of TB include:
Progressive primary TB due to a failed immune
response with subsequent disease progression.
Miliary TB massive haematogenous dissemination.
Post-primary/reactive TB presents in adults, with
reactivation of dormant organisms after several
asymptomatic years. Usually the apical and posterior
segments of the upper lobes are involved (8595%),
the superior segment of the lower lobes being less
commonly affected. Radiological presentation is with
cavitation, fibrosis, empyema, miliary TB,
tuberculoma, mycetoma. Adenopathy is not a major
feature.
HRCT can be useful for further evaluation and TB presents
with nodules in a centrilobular distribution due to
endobronchial spread. This gives a tree in bud appearance.
The differential diagnosis for centrilobular nodules includes
TB, endobronchial metastases, allergic bronchopulmonary
aspergillosis (ABPA), obliterative bronchiolitis and hypersensitivity pneumonitis. Figures 2b and 2c show axial CT
images demonstrating multiple poorly defined centrilobular nodules giving a tree in bud appearance in a
young male Asian patient with TB. Note that there is
sparing of the subpleural areas with no nodules seen within
5 mm of the pleural surfaces or fissures.
Practical tips
TB is a multisystem disorder with haematogenous spread
to multiple other sites. On a chest radiograph look for TB
discitis and TB affecting shoulder joints. The most
commonly affected joint is the hip with features of
monoarticular involvement. Radiographic changes of loss
of joint space, peripheral bone erosions and juxta-articular
osteoporosis are seen, which can lead to ankylosis of the
joint and limb shortening (2d).
Further management
Respiratory referral with a view to sputum cytology/
bronchoscopy to identify the acid fast bacilli.
Further reading
2b
2c
16
2d
Chest Imaging
CASE 3
Cases 3, 4
3a
History
A 65-year-old male presented with
progressive dyspnoea and weight loss.
CASE 4
History
A 68-year-old male presented with
haemoptysis.
17
Answer 3
Chest Imaging
ANSWER 3
Observations (3a)
CT image of the thorax shows diffuse, irregular and
nodular pleural thickening in the left hemithorax. This
measures upwards of 1 cm in thickness and also involves
mediastinal pleura. No focal intraparenchymal pulmonary
abnormality is seen on these soft tissue window settings and
there is no visible mediastinal mass. Taken together with
the clinical history, the features are suspicious of
mesothelioma, though metastases cannot be excluded.
With regard to the former, the rest of the CT scan should
be examined for features of asbestos-related pleural disease
and asbestosis. An occupational history should also be
taken.
Diagnosis
Malignant mesothelioma.
Differential diagnosis
For diffuse pleural thickening:
Malignant mesothelioma.
Pleural metastases usually from adenocarcinoma
primary, e.g. breast, lung.
Empyema.
Pleural fibrosis from infection tuberculosis, fungal.
Discussion
Malignant mesothelioma is a rare primary tumour of the
pleura, seen more commonly in men, with a peak incidence
in the 7th8th decades. Aetiology is strongly associated
with asbestos exposure, and underlying lung changes from
asbestos are often seen in association. Between 5 and 10%
of asbestos workers will develop mesothelioma with a latent
period of up to 45 years. The parietal pleura is usually
involved and spread is locally to the chest wall,
mediastinum, diaphragm and peritoneum; there is
lymphatic spread to the hilar and mediastinal nodes and
Practical tips
Pleural thickening involving the mediastinal pleura is
a very good sign for mesothelioma.
Bilateral, calcified pleural plaques are characteristic of
asbestos exposure. (Figure 3b is a single axial CT
image showing calcified pleural plaques, which are
characteristic of asbestos exposure.) When identified,
examine the CT closely for evidence of asbestosis as
this may have greater immediate implications for the
patient in terms of morbidity (and in the UK at least,
financial compensation).
Further management
Pleural biopsy is required to confirm the diagnosis
and to differentiate mesothelioma from pleural
metastatic disease, which can show some response to
chemotherapy.
Discussion within a lung cancer multidisciplinary team
is required.
A detailed occupational history needs to be taken
since asbestos-related disease may entitle the sufferer
to compensation.
Further reading
Wang ZJ, Reddy GP, Gotway MB, et al. (2004).
Malignant pleural mesothelioma: evaluation with CT,
MR imaging, and PET. Radio Graphics 24: 105119.
3b
18
Answer 4
Chest Imaging
Case 5
ANSWER 4
Observations (4)
Discussion
Diagnosis
Miliary metastases from previous bronchogenic carcinoma.
Differential diagnosis
For miliary nodules:
Miliary metastases.
TB.
Sarcoid.
Chronic extrinsic allergic alveolitis.
Coal workers pneumoconiosis (CWP).
Histoplasmosis.
Of a completely opaque hemithorax:
Total lung collapse.
Pneumonectomy looks like total collapse but there
will be evidence of thoracotomy.
Huge pleural effusion volume expansion rather than
volume loss, i.e. the mediastinum will be displaced
away from the side of opacity.
CASE 5
Practical tips
This fairly straightforward case illustrates how films
used to test candidates in postgraduate exams will
often require piecing together of the pieces rather
than being presented with miliary shadowing alone
and being asked for a differential.
As always, look for other clues on the film. A primary
malignancy may be evident as a mastectomy, a thyroid
mass in the neck, a bony sarcoma on the edge of the
film or signs of previous lung cancer, as in this case.
Check the patient data for likely ethnicity to help
predict likelihood of TB.
Further management
Comparison with previous chest radiographs to look
for new features is very useful and should be done in
both clinical and exam situations.
A chest CT will characterize these changes in greater
detail.
5a
History
A 40-year-old male presented with
haemoptysis and renal impairment.
19
Answer 5
Chest Imaging
ANSWER 5
Observations (5a)
This frontal chest radiograph shows multiple relatively thick
walled cavitating nodules throughout both lungs.
Mediastinal contours are normal with no evidence on the
film of hilar or mediastinal lymphadenopathy. No pleural
effusion can be seen. Appearance of the shoulder joints and
the lateral ends of the clavicles is normal.
Diagnosis
Wegeners granulomatosis.
Differential diagnosis
For multiple cavitating lung nodules:
Neoplasia: metastases in particular, squamous cell,
sarcoma, melanoma and colorectal tumours.
Infection: bacterial septic emboli, TB, aspergillosis and
other fungal organisms.
Collagen vascular disease: Wegeners granulomatosis,
rheumatoid nodules.
Granulomatous disease: histiocytosis X and
sarcoidosis.
Vascular: pulmonary emboli with infarction.
Discussion
This is a systemic condition characterized by necrotizing
granulomata and a necrotizing vasculitis affecting medium
to small vessels. Pulmonary Wegeners granulomatosis has
a variety of presentations, which include:
Widespread nodules that typically cavitate, have
varying sizes (up to several centimetres) and show no
zonal predilection. Figure 5b is a single axial CT
image showing left lower lobe pulmonary nodules that
are relatively thick walled and some of which are
demonstrating cavitation. A coronal reformat of the
same patient is also shown (5c).
5b
20
Practical tips
There is a long differential for cavitating lung nodules
so look for clues on the film to point towards an
underlying diagnosis and also be guided by the
history. Check the bones for evidence of rheumatoid
arthritis and primary/secondary bone malignant
lesions.
A history of haemoptysis and renal impairment with
pulmonary abnormalities on the chest radiograph
brings to mind the diagnoses of Wegeners
granulomatosis and Goodpastures syndrome. Renal
failure causing fluid overload may also result in
pulmonary oedema that may be blood tinged.
Further management
Initial management should be referral to a respiratory
physician to exclude malignant/infective causes for
cavitating nodules.
5c
Chest Imaging
CASE 6
Cases 6, 7
6a
History
A 45-year-old female presented with
progressive
dyspnoea
and
an
inflammatory arthropathy.
CASE 7
History
A 70-year-old factory worker presented
with progressive dyspnoea.
21
Answer 6
Chest Imaging
ANSWER 6
Observations (6a)
This frontal chest radiograph demonstrates a well defined
pulmonary nodule in the right lower zone. This appears to
be a solitary lesion. Arthropathy is noted at the left shoulder
joint with associated erosion of the lateral end of the clavicle
this suggests background rheumatoid arthritis. The
nodule is therefore likely to be a rheumatoid pulmonary
nodule, though other pathology such as a malignant
nodule cannot be excluded and follow-up is therefore
required. There is no evidence of pulmonary fibrosis.
Further management
Follow-up of single pulmonary nodules is advised to ensure
that the nodule is not a developing primary bronchogenic
carcinoma. Fleischner Society guidelines (Table 1) suggest
dividing patients into high-risk (smokers and other risk
factors) and low-risk categories and then organizing
subsequent follow-up depending on the size of the nodule.
Diagnosis
Rheumatoid lung.
Further reading
Differential diagnosis
For lateral end of clavicle erosion:
Arthropathies rheumatoid arthritis, gout,
scleroderma.
Hyperparathyroidism.
Post-traumatic osteolysis (6b).
Infection osteomyelitis.
Neoplastic conditions myeloma, metastases.
Hereditary disorders cleidocranial dysostosis,
pyknodysostosis, HoltOram syndrome.
6b
Discussion
Rheumatoid lung manifestations can be seen in up to 50%
of RA patients. The lung changes are more commonly
found in men. CXR features of RA include:
Interstitial fibrosis that predominantly affects the
lower zones.
Rheumatoid lung nodules these are usually multiple,
and commonly located in the lung periphery or
pleurally based. They often cavitate but dont calcify.
Pleural effusion usually this is a unilateral exudate.
More common in men.
Caplans syndrome is a condition characterized by
pneumoconiosis and RA in coal workers.
Practical tips
Look for associated bone abnormalities if rheumatoid
is suspected, e.g. resorption of the lateral ends of
clavicles, erosion of the acromioclavicular,
sternoclavicular and shoulder joints.
Low risk
No follow-up
46
68
>8
22
High risk
CT at 12 months, nil further if
unchanged
CT at 612 months, then 1824
months if unchanged
CT at 6 months, then 912 months
and then 24 months if unchanged
CT at 3, 9 and 24 months +/ PET
CT and biopsy
Answer 7
Chest Imaging
Case 8
ANSWER 7
Observations (7)
There is widespread abnormal interstitial opacity
throughout both lungs with no zonal predominance. This
is predominantly of tiny nodules with some reticulation.
Poorly defined heart border and hemidiaphragms indicate
subpleural involvement. There are large, poorly defined
conglomerate masses in both upper zones with surrounding fibrotic changes. These findings are in keeping with
progressive massive fibrosis in a patient with underlying
pneumoconiosis.
Diagnosis
Progressive massive fibrosis (PMF).
Differential diagnosis
For mass lesion with background pneumoconiosis:
PMF.
Bronchogenic carcinoma (increased incidence of
adenocarcinoma in scarred lung).
Granuloma (TB, histoplasmosis).
Caplans syndrome (rheumatoid nodules in those
with coexisting rheumatoid).
Any other parenchymal lesion can incidentally cooccur.
Practical tips
When mass lesions appear in patients with background
pneumoconiosis, remember that this may be PMF but that
they are also at increased risk of adenocarcinoma.
Further management
Discussion
Pneumoconiosis is a parenchymal lung reaction to chronic
inorganic dust exposure. Some typical appearances on chest
radiography are:
CASE 8
8a
History
A 30-year-old male presented with
haemoptysis and shoulder pain.
23
Answer 8
Chest Imaging
ANSWER 8
Observations (8a)
There are several well defined soft tissue density nodules
throughout both lungs with no zonal predominance. The
right humerus is seen on the edge of the film and is
abnormal in appearance with mottled sclerotic density and
apparent periosteal reaction. Further imaging of it is
required but the suspicion from this film must be of a
sarcoma of the right humerus with associated pulmonary
metastases.
8b
Diagnosis
Lung metastases with underlying osteosarcoma.
Differential diagnosis
For multiple lung nodules:
Neoplastic:
Malignant metastases.
Benign arteriovenous malformation (AVM).
Infectious:
Granulomas TB, histoplasmosis,
coccidioidomycosis, cryptococcus.
Abscesses.
Septic emboli.
Noninfectious:
Wegeners granulomatosis.
Rheumatoid arthritis (RA).
Infarcts.
Sarcoid.
Amyloid.
Discussion
An AP view of the proximal right humerus from this
patient is shown (8b). It demonstrates a pathological
fracture of the right upper diaphysis with a poorly defined
underlying lesion involving the metadiaphysis. This has a
wide zone of transition with lytic mottled areas and
sclerosis. Periosteal reaction is evident and appearances
most likely indicate an osteosarcoma.
Metastases to the lung are common and are seen in up
to 30% of all patients with malignancy. Common primary
tumours are breast, prostate, colon, renal cell carcinoma,
melanoma and osteogenic sarcoma. Some clue to the
underlying primary can be suspected from the appearances
of the metastatic lesion. Squamous cell carcinomas, colon,
melanoma, osteosarcoma and cervix metastases are more
likely to cavitate. Breast, thyroid, osteosarcoma, testes and
ovarian metastases are more likely to calcify. Metastases are
commonly multiple and are found in a subpleural location.
8c
Practical tips
Carefully check that the nodules are truly pulmonary.
If no nodules project outside a region of lung covered
by ribs, could they be bony? Do nodules extend into
the subcutaneous tissues? Figure 8c shows multiple
skin nodules in neurofibromatosis masquerading as
pulmonary nodules!
8c Chest radiograph of a patient with
neurofibromatosis type 1 with multiple skin nodules.
24
Answer 8
Chest Imaging
Case 9
Further reading
Winer-Muram HT (2006). The solitary pulmonary
nodule. Radio lo gy 239: 3449.
Further management
CT chest can identify further nodules and can help to
characterize them, i.e. looking for central necrosis, fat,
calcification, cavitation.
CASE 9
9a
History
A 45-year-old male smoker presented
with a cough.
9b
25
Answer 9
Chest Imaging
ANSWER 9
Observations (9a, 9b)
Discussion
Diagnosis
Chest wall lipoma.
Practical tips
Differential diagnosis
For pleural lesions:
Metastasis lung and breast are the most common
primaries, with other adenocarcinomas such as ovary,
uterus, pancreas.
Pleural plaques.
Loculated pleural effusion.
Haematoma.
Lipoma.
Neurofibroma/schwannoma.
Rib lesions such as tumour or even healing fracture
can be hard to differentiate from pleural lesions.
(Figure 9c is an axial CT image showing a rib-based
lesion causing complete destruction of the posterior
right 8th rib. The patient had myeloma and
appearances are those of a plasmacytoma.)
Further management
No further treatment required for this benign lesion.
9c
26
Chest Imaging
CASE 10
Cases 10, 11
10a
History
A 76-year-old male presented with
chest pain.
CASE 11
11a
History
A 67-year-old male presented with
shortness of breath.
27
Answer 10
Chest Imaging
ANSWER 10
Observations (10a)
This AP chest radiograph demonstrates a large mediastinal
mass on the left. The arch of the aorta and proximal
descending aorta are not seen separate from this mass,
which indicates that it arises from the posterior mediastinum. There is curvilinear calcification in the lateral aspect
of this mass, which would suggest that the lesion is in fact
a dilated aneurysmal thoracic aorta. Comparison with old
films would be useful to assess any change.
Diagnosis
Thoracic aortic aneurysm.
Differential diagnosis
Of posterior mediastinal mass:
Thoracic aortic aneurysm.
Dilated oesophagus.
Hernia hiatus, Bochdaleks.
Neurogenic tumour neurofibroma, schwannoma,
ganglioneuroma.
Spinal abscess.
Extramedullary haematopoiesis.
Of anterior mediastinal mass:
Thymoma.
Teratoma.
Thyroid enlargement with retrosternal extension.
Lymphoma.
Practical tips
Lateral films can be very useful in better localizing
mediastinal masses.
Further management
If there is clinical concern then CT is usually the next
investigation of choice.
Discussion
An axial CT image (10b) of the chest with IV contrast
shows the descending aortic aneurysm. Typical radiological
appearances are of a mediastinal mass the wide tortuous
aorta with peripheral curvilinear calcification. Normal CT
measurements for the thoracic aorta are <3.5 cm diameter
for the ascending aorta and <2.5 cm for the thoracic
descending aorta. Surgical repair is considered over 6 cm.
In the acute situation, where no old films are available,
differentiation from an acute aortic dissection may be
necessary. In acute aortic dissection there can be widening
of the mediastinum, an irregular fuzzy appearance to the
aortic outline and displacement of calcification with
additional soft tissue identified lateral to calcification (due
to false channel formation).
Characterizing the position of mediastinal masses is
useful on plain radiography in order to narrow the
differential diagnosis:
Posterior mediastinum is the space between the
posterior aspect of the heart and the thoracic spine,
and contains descending aorta, oesophagus, azygous
veins and thoracic duct.
Middle mediastinal space contains heart and great
vessels.
28
10b
Answers 10, 11
Chest Imaging
10c
10d
ANSWER 11
Observations (11a)
Pleural pseudotumour.
Non-infectious:
Wegeners granulomatosis.
Rheumatoid arthritis (RA).
Infarct.
Sarcoid.
Amyloid.
Congenital:
Bronchogenic cyst.
Sequestration.
Extrapulmonary:
Pleural mass/fluid.
Rib fracture/lesion.
Subcutaneous lesion.
External artefact.
Differential diagnosis
Discussion
Diagnosis
(co nt.)
29
Answer 11
Chest Imaging
Practical tips
Important features in differentiating solitary lesions
include:
Growth rate lesions that dont change in size
over a period of 2 years can be considered benign.
Tumour doubling times (time taken for volume of
nodule to increase twofold) have been reported
between 1 and 18 months.
Margins irregularity, lobulation and spiculation
of the lesions edge are a good indicator of
malignancy. However, 30% of lesions with smooth
margins are not benign usually representing
metastases.
Presence of fat this is usually a sure sign of
benignity and suggests the diagnosis of a
hamartoma. Very occasionally renal cell carcinoma
and liposarcoma metastases can also contain fat.
Calcification this is seen in both benign and
malignant conditions. Benign lesions usually have
calcification with a central nidus, laminated or
popcorn appearance. Calcification in malignant
lesions usually appears stippled, amorphous or
diffuse. Stippled calcification is seen in mucin
secreting tumour metastases, e.g. colon, ovary.
Further management
Lateral CXR can be helpful in these cases and if there is
still concern then CT chest will usually resolve the issue.
(See Case 6, Tab le 1 for further management of single
pulmonary nodule.)
11b
30
Chest Imaging
CASE 12
Case 12
12a
History
A 69-year-old male smoker with
ischaemic heart disease, presented with
increasing dyspnoea over the last 2
months.
12b
31
Answer 12
Chest Imaging
ANSWER 12
Observations (12a, 12b)
The heart looks enlarged but as this is an AP radiograph, it
is not possible to be sure. There is a diffuse, bilateral
increase in reticular interstitial opacity with Kerley B lines
in the right lower zone best seen on the close-up (12b).
The left hilum is enlarged, and there is a pulmonary nodule
in the left upper zone measuring approximately 1.5 cm. A
tiny left pleural reaction is also noted.
The most likely explanation is that the patient has a left
upper lobe tumour with left hilar adenopathy and
lymphangitis carcinomatosa. However, given the history
of heart disease and the rather subjective cardiomegaly, it
is possible that he could have lung cancer and coexisting
left heart failure. A repeat film after treatment for heart
failure might help clarify, but he is likely to need staging
of the suspected tumour with CT anyway, and this may
answer the question.
Diagnosis
thickening. In addition, there are small peripheral subpleural nodules. Heart failure produces similar appearances
on plain film and CT, though the thickening is more likely
to be smooth and there will not be the associated lymphadenopathy that is often present in lymphangitis. Like heart
failure, lymphangitis usually produces bilateral changes.
Practical tips
When lymphangitis is diagnosed, look for other signs
of malignant spread on available images, i.e. lung
metastases, bone deposits.
CT imaging findings of subpleural nodules and
reticulation with interlobular septal thickening are the
best diagnostic features. However, if it remains
impossible to differentiate interlobular septal
thickening of heart failure from lymphangitis on CT
scanning, repeat imaging (chest radiograph or perhaps
follow-up CT) after treatment for heart failure may
resolve the issue.
Further management
Differential diagnosis
For tumours causing lymphangitis (anatomically from top
down):
Larynx.
Thyroid.
Breast.
Stomach.
Pancreas.
Colon.
Cervix.
Further reading
Connolly JE, Erasmus JJ, Patz EF (1999). Thoracic
manifestations of breast carcinoma: metastatic disease
and complications of treatment. Clinical Radio lo gy
54(8): 487494.
Discussion
Certain tumours show a propensity to invade the lung
interstitium, both the connective tissue and the lymphatics.
Lymphatics become distended by the tumour itself, and
also because of congestion resulting from tumour
obstruction. Symptoms include dyspnoea and cough.
Plain film signs are of increased reticular/reticulonodular interstitial markings, Kerley A and Kerley B lines.
CT shows irregular thickening of the interlobular septae,
along the central bronchovascular bundles and subpleural
32
12b
12b Kerley B
septal line.
Chest Imaging
CASE 13
Cases 13, 14
13
History
A 36-year-old female, otherwise fit and
well, presented with acute dyspnoea and
left sided chest pain.
CASE 14
14a
History
A 55-year-old man presented with
dysphagia.
33
Answers 13, 14
Chest Imaging
ANSWER 13
Observations (13)
There is a large, well defined, solitary, unilocular thin
walled cyst in the medial aspect of the left middle zone.
This contains an air-fluid level. A moderate sized left sided
pneumothorax is evident with signs of mediastinal and
tracheal shift to the right suggesting that this is a tension
pneumothorax. Immediate treatment of this tension
pneumothorax is required.
The air-containing mass has presumably ruptured and
led to a spontaneous pneumothorax. The fact that this
patient is young and otherwise in good health makes most
of the causes of large cavitating/cystic masses unlikely.
After initial treatment, a search for previous films should
be made to see if this is a longstanding benign lesion.
Otherwise, further investigation, perhaps with CT, will be
required.
Practical tips
Differential diagnosis
Further management
Diagnosis
Further reading
Discussion
Bronchogenic cysts are usually located in the mediastinum
(85%) but can also be intrapulmonary in location (15%).
They are more commonly found in the lower lobes and
ANSWER 14
34
Observations (14a)
Diagnosis
Differential diagnosis
Of a veil-like opacity over a hemithorax:
Left upper lobe collapse.
Pleural effusion in the supine position.
Rotated patient position.
Overlying chest wall abnormality, e.g. gynaecomastia.
Unilateral airspace opacity.
Normal, i.e. it is actually the other side that is
hypodense!
Of a completely opaque hemithorax:
Total lung collapse.
Pneumonectomy looks like total collapse but there
will be evidence of thoracotomy.
Answer 14
Chest Imaging
14c
Discussion
The various lobar collapses have their own characteristic
appearances but evidence of volume loss is fundamental.
Signs to look for include:
Elevation or tenting of the hemidiaphragm.
Elevation or depression of the hilum note that the
left is normally higher than right.
Mediastinal shift in the direction of the collapse.
Elevation or depression of the horizontal fissure.
Increased lucency or splayed vessels in the remaining
hyperexpanded lobe.
In older adults, an obstructing central tumour must always
be excluded. When causing upper lobe collapse, this can
sometimes produce the characteristic S sign of Golden
(14b). The right upper lobe collapses into a triangular
upper zone opacity, limited inferiorly by the horizontal
fissure. However, the central mass produces an overall S
configuration with the fissure. Figures 14c and 14d are axial
CT images in a patient with subtotal collapse of the right
upper lobe with medial collapse of the lobe and significant
volume loss as demonstrated by anterior movement of the
fissures. A coronal CT reformatted image (14e) again
shows subtotal collapse of the right upper lobe with volume
loss.
14d
(co nt.)
14b
14e
35
Answer 14
Chest Imaging
14f
Practical tips
Differentiating collapse and consolidation can
sometimes be difficult since they often coexist. Look
for signs of volume loss as described above.
Lateral radiographs are useful in suspected collapse.
Look for other evidence on the film of a primary
bronchogenic tumour, e.g. metastases to lung and
bone, previous thoracotomy and radiotherapy change.
Check the position of endotracheal tube if present it
may have passed too far, occluding a bronchus and
causing lung/lobar collapse. (Figure 14h shows left
total lung collapse and right upper lobe collapse due
to passage of the endotracheal tube into the bronchus
intermedius; the SengstakenBlakemore tube in situ is
unrelated.)
Further management
In the adult patient with no obvious underlying cause, a
central or endobronchial tumour needs to be excluded and
respiratory referral with a view to bronchoscopy should be
made.
14g
36
14h
Chest Imaging
CASE 15
Cases 15, 16
15a
History
A 68-year-old male presented with
slowly progressive dyspnoea.
CASE 16
16
History
A 40-year-old male presented with a
long progressive history of dyspnoea
and more recent onset cyanosis.
37
Answer 15
Chest Imaging
ANSWER 15
Observations (15a)
This chest radiograph demonstrates bilateral lower zone
interstitial reticular opacity with evidence of basal volume
loss demonstrated by descent of both hila. The interstitial
opacity gives the heart an irregular shaggy border. These
appearances are in keeping with basal fibrosis. There is a
calcified pleural plaque related to the right hemidiaphragm.
The combination of basal fibrosis with pleural disease
would suggest asbestos exposure with pulmonary asbestosis
and pleural plaques.
Diagnosis
Pulmonary asbestosis.
Discussion
Pulmonary asbestosis is a chronic progressive fibrotic
condition secondary to chronic asbestos exposure.
Crocidolite (blue) asbestos fibres are most commonly
associated with malignant disease and pleural disease.
Radiological features are of a fibrosing alveolitis that
predominantly affects the bases and is indistinguishable
from other causes. Fibrosis can progress to result in
progressive massive fibrosis, but this again predominates
at the lung bases. Pulmonary asbestosis has a latency period
of ~40 years and therefore pleural changes are usually seen
prior to lung parenchymal changes.
Other features of asbestos exposure include:
Pleural effusion this is the earliest pleural
abnormality, with a latency of ~10 years.
Focal pleural plaques have a latency of 2040 years.
Diffuse pleural thickening.
Pleural calcification.
Rounded atelectasis this is also known as folded
lung and arises due to infolding of thickened pleura
with associated subsegmental atelectasis. Most
commonly seen in the lower lobes, it has the
appearance of a rounded subpleural mass abutting
15b
38
Practical tips
Multiple pleural plaques are characteristic for previous
asbestos exposure (15c).
Look for signs of malignancy in patients with asbestos
exposure remember the increased risk of pleural and
pulmonary malignancy. Pulmonary masses should be
investigated with CT characteristic findings may
permit a confident diagnosis of folded lung in some
cases.
Asbestosis is the odd one out among the inorganic
dusts causing pulmonary fibrosis. The other
fibrogenic dusts cause upper zo ne fibrosis.
Further management
Systemic symptoms, e.g. weight loss, should be
carefully investigated to exclude mesothelioma or
bronchogenic carcinoma, for which these patients are
at increased risk.
In cases where there is still clinical concern about an
area of possible folded lung despite imaging,
percutaneous biopsy may be required to exclude a
malignancy.
Further reading
Akira M, Yamamoto S, Yokoyama K, et al. (1990).
Asbestosis: high-resolution CT-pathologic
correlation. Radio lo gy 176: 389394.
15c
Answer 16
Chest Imaging
Case 17
ANSWER 16
Observations (16)
This frontal chest radiograph shows extreme cardiomegaly.
There is marked dilatation of the central and main pulmonary arteries with pruning of peripheral pulmonary
arteries. No diffuse lung abnormality is seen.
The findings are indicative of pulmonary hypertension.
Given the gross cardiomegaly, a left to right shunt is the
most likely cause. However, cyanosis should not occur and
its presence suggests the shunt has reversed, that is, the
patient has developed Eisenmengers syndrome.
Diagnosis
Pulmonary arterial hypertension from an undiagnosed
ventricular septal defect (VSD) progressing to
Eisenmengers syndrome.
Discussion
Pulmonary arterial hypertension is diagnosed by a sustained
mean pressure >20 mmHg (systolic >30 mmHg, diastolic
>15 mmHg). Radiological features on a plain chest
radiograph that suggest the diagnosis are:
Increase in size of the main pulmonary artery.
Reduction in size of peripheral pulmonary arteries
known as peripheral pruning.
Right heart enlargement.
Calcification of the central pulmonary arteries a late
but characteristic sign.
Parenchymal mosaic attenuation pattern seen on
HRCT.
Primary pulmonary hypertension is idiopathic. The
condition can also arise secondary to pulmonary disease or
CASE 17
Practical tips
On a plain chest radiograph, hilar lymphadenopathy
can mimic pulmonary arterial hypertension. Clinical
history here is vital and CT should be subsequently
undertaken in the right clinical setting.
The diameter of the main pulmonary artery should be
less than that of the ascending thoracic aorta. Reversal
of this ratio is a sign of pulmonary hypertension.
Further management
Primary pulmonary hypertension has no cure and a dismal
prognosis. It is a diagnosis of exclusion so all underlying
causes of secondary pulmonary hypertension must be
investigated. Cardiology referral with a view to echocardiography would be required initially.
17a
History
A 50-year-old female presented
with progressive dyspnoea and
intermittent cyanosis of the
fingers.
39
Answer 17
Chest Imaging
ANSWER 17
Observations (17a)
This frontal chest film shows abnormal reticular interstitial
opacity at both lung bases, though there are no features to
indicate significant volume loss at the present time. A large
area of calcinosis is noted in the soft tissues around the
upper right humerus. The combination of findings and
clinical history suggests a diagnosis of systemic sclerosis
with lower zone pulmonary fibrosis and Raynauds
phenomenon.
Diagnosis
Lower zone pulmonary fibrosis due to systemic sclerosis.
Differential diagnosis
For lower zone pulmonary fibrosis:
Idiopathic pulmonary fibrosis (IPF) (cryptogenic
fibrosing alveolitis CFA).
Connective tissue disorders systemic sclerosis,
rheumatoid.
Asbestosis.
Drugs especially certain cytotoxics, e.g.
cyclophosphamide, bleomycin, busulphan, etc.
Discussion
This autoimmune disease has also been known as
scleroderma, with a subgroup known as CREST syndrome.
Current nomenclature is systemic sclerosis with diffuse or
limited scleroderma, the latter being the equivalent of
CREST syndrome. The condition is three times as
common in females and typically presents in the 4th5th
decades. A variety of autoantibodies may be present
including ANA and rheumatoid factor. Clinical features
are many and varied but include:
Musculoskeletal thickened skin, soft tissue
calcinosis, Raynauds, erosive arthritis (see Case 152).
Lungs lower zone pulmonary fibrosis, aspiration.
Oesophagus hypotonia results in dilatation and
dysphagia. Incompetence of the gastro-oesophageal
sphincter results in reflux and consequent peptic
stricture, aspiration, etc.
Small bowel dilatation and slow transit result in
bacterial overgrowth and malabsorption. Barium
studies show hidebound appearance due to fibrosis
pulling the valvulae closer together.
Pseudosacculations and pneumatosis in small and
large bowel.
Further management
HRCT is the imaging choice in diagnosis and follow-up
of interstitial lung disease. CT imaging findings of fibrosis
include lung volume reduction, subpleural reticulation,
interlobular septal thickening and traction bronchiectasis.
17b
Practical tips
Once lower zone pulmonary fibrosis has been noted
on the chest radiograph, examine the film for the
following features that may indicate a specific
diagnosis:
Dilated oesophagus systemic sclerosis (see Case
152).
Erosions of the lateral ends of clavicles
rheumatoid.
Pleural plaques asbestosis.
40
Chest Imaging
CASE 18
Cases 18, 19
18a
History
A 33-year-old male presented with back
pain and progressive dyspnoea.
CASE 19
History
A 59-year-old male presented with left arm
pain on activity.
19
41
Answer 18
Chest Imaging
ANSWER 18
Observations (18a)
Plain radiograph of the chest shows changes of upper zone
fibrosis with elevation of both hila and upper zone reticular
opacities. In addition, there is a cavity in the left upper
zone containing a soft tissue density mass with surrounding
air crescent. These appearances would be consistent with
a mycetoma. The patient also has a marked kyphosis with
the head obscuring the lung apices. Moreover, on close
inspection, there is a hint of syndesmophyte formation
along the right lateral aspect of thoracic spine.
The combination of findings is consistent with upper
zone fibrosis associated with ankylosing spondylitis. There
is mycetoma formation in the fibrotic cavity in the left
upper zone.
Diagnosis
Practical tips
Ankylosing spondylitis.
Differential diagnosis
For upper zone fibrosis (mnemonic STRAD):
Sarcoidosis.
TB.
Radiation.
Ankylosing spondylitis.
Dust inhalation inorganic (e.g. silica) and organic
(i.e. chronic extrinsic allergic alveolitis).
Discussion
Ankylosing spondylitis is an autoimmune disease that most
commonly manifests as a seronegative arthropathy,
predominantly affecting the axial skeleton (initially
sacroiliac joints then thoracic and lumbar spine). It usually
presents in the 2nd4th decade and more frequently affects
men (sex ratio of ~5:1). As well as bone involvement, there
are respiratory and cardiac manifestations. Respiratory
manifestations are seen in ~1% of cases and features
include:
Upper lobe pulmonary fibrosis.
Reticular/reticulonodular opacities in lung apices.
Further management
Multidisciplinary management is required in this
multisystem disease.
18b
42
Answer 19
Chest Imaging
Case 20
ANSWER 19
Observations (19)
Two spot images from an angiogram investigation at the
level of the aortic arch are presented. Both images show the
left shoulder joint in an abducted position. The left hand
image shows contrast filling of the aortic arch with filling
of the brachiocephalic trunk and left common carotid
artery. There is filling of the proximal subclavian artery but
then there is a complete occlusion with no filling beyond
it. The right hand image shows a slightly delayed film with
contrast seen in the left vertebral artery (best seen at the
level of the C3/4) providing filling of the distal left
subclavian artery.
Practical tips
Diagnosis can be made noninvasively by US by identifying
reversal of Doppler flow in the vertebral artery.
Diagnosis
Further management
Discussion
This is a condition that is usually acquired and caused by
atherosclerotic disease. Stenosis of the subclavian artery
results in stealing of blood to the arm via retrograde flow
in the ipsilateral vertebral artery. Other acquired causes
include vasculitis (Takayasu), embolism, aortic dissection,
radiation fibrosis and chest trauma. Congenital causes are
uncommon. Clinical features include:
Left arm is more commonly involved than the right.
Reduced BP by up to 40 mmHg in the affected arm.
Delayed/weak pulse in the affected arm.
CASE 20
Further reading
Chung JW, Park JH, Im JG, et al. (1996). Spiral CT
angiography of the thoracic aorta. Radio Graphics 16:
811824.
20a
History
A 44-year-old male having a preemployment chest radiograph.
43
Answer 20
Chest Imaging
ANSWER 20
Observations (20a)
This chest radiograph shows multiple fine, sand-like, tiny
calcified lesions measuring less than 1 mm in diameter,
spread throughout both lungs. Both lungs are of normal
volume. No other abnormality is seen.
Further management
No further management is required in this benign
condition.
Diagnosis
Alveolar microlithiasis.
Further reading
Differential diagnosis
20b
20c
Discussion
This is a rare condition that affects adults in the 4th6th
decades, resulting in calcification within the alveoli. Usually
these patients are asymptomatic, however they can present
with dyspnoea on exertion. Radiological appearances can
be quite striking with diffuse tiny calcified nodules <1 mm
in diameter spread throughout both lungs. The middle and
lower zones are preferentially affected. Serum calcium and
phosphate are normal. Differentiation from the causes
below is usually made by the normal biochemistry,
characteristic radiological appearances and the paucity of
clinical symptoms relative to the marked radiological
changes.
Practical tips
Clinical history is of vital importance when narrowing down
a list of differential diagnoses. Alveolar microlithiasis is a
good example of where marked radiological changes are
associated with a relative lack of symptoms. A simple
44
Chest Imaging
CASE 21
Cases 21, 22
21a
History
A 28-year-old patient presented with
deteriorating chronic dyspnoea.
CASE 22
22
History
A 45-year-old male presented with
cardiac arrhythmia and shortness of
breath.
45
Answer 21
Chest Imaging
ANSWER 21
Observations (21a)
Practical tips
Diagnosis
Allergic bronchopulmonary aspergillosis (ABPA).
Differential diagnosis
For a flitting pneumonia:
Eosinophilic pneumonia.
Aspiration pneumonia.
ABPA.
Cryptogenic organizing pneumonia (COP).
Discussion
This is a hypersensitivity condition seen in longstanding
asthmatics with sensitivity towards aspergilli. It occurs in
12% of asthmatics and more commonly (~10%) in
patients with cystic fibrosis. Pulmonary features of the
disease are:
Pulmonary infiltration with eosinophils, which
presents as a migratory/flitting pneumonitis of patchy
alveolar infiltrates more commonly seen in the upper
lobes.
Cystic bronchiectasis with an upper lobe
predominance that is usually central, producing ring
shadows on plain radiographs.
Mucoid impaction in dilated central bronchioles,
producing the finger in glove appearance. This can
result in segmental/lobar collapse.
Lobar consolidation.
Axial CT images of a young female patient with ABPA are
shown (21b, 21c). Figure 21b shows dilated mucousfilled/plugged upper lobe bronchi, which can be best
appreciated on coronal reformats. Figure 21c demonstrates
the typical cystic dilated bronchi with further evidence of
mucous-plugging.
21b
46
Further management
Referral to chest physician is appropriate with further
imaging follow-up with HRCT.
Further reading
Williams SM, Jones ET (1997). General case of the day.
Allergic (or hypersensitivity) bronchopulmonary
aspergillosis (ABPA). Radio Graphics 17: 15971600.
21c
21d
Answer 22
Chest Imaging
Case 23
ANSWER 22
Observations (22)
This is a single long axis view of the left ventricle at delayed
gadolinium enhancement phase. The image shows delayed
enhancement of the septal, apical and lateral myocardium
with sparing of the endocardium. This pattern of delayed
intramyocardial enhancement with a normal endocardium
suggests an infiltrative/inflammatory process.
Diagnosis
Cardiac sarcoid.
Practical tips
Discussion
At autopsy cardiac sarcoid is seen in 2025% of patients
with sarcoidosis. However, as few as 5% exhibit any clinical
signs. Clinical presentation of sarcoid is with cardiac
arrhythmias, cardiomyopathy and heart failure.
CASE 23
Further management
Look at CXR for respiratory changes of sarcoid.
23a
History
A 50-year-old male patient
presented with orthopnoea.
47
Answer 23
Chest Imaging
ANSWER 23
Observations (23a)
This chest radiograph shows evidence of previous surgery
there are sternotomy wires and a metallic mitral valve
replacement. The heart is enlarged with a cardiothoracic
ratio of 21:32. There is a double density seen through
the right heart a sign of left atrial enlargement. Multiple,
small (15 mm) calcium density nodules are seen in both
lungs with mid and lower zone predominance. Upper zone
venous diversion and a tiny right pleural effusion suggest
pulmonary venous hypertension.
Appearances indicate that the patient has had surgical
mitral valve replacement, but there are persisting features of
mitral valve disease and signs of left heart failure. He
should undergo further assessment of valve and left heart
function. The high-density pulmonary nodules indicate
pulmonary haemosiderosis, a consequence of elevated
pulmonary venous pressure over many years.
Practical tips
Diagnosis
Mitral valve disease.
Discussion
The most common cause of mitral valve disease is
rheumatic heart disease, with presentation most commonly
seen in middle aged females. It results in left atrial
enlargement and pulmonary venous hypertension/heart
failure.
Radiographic signs of mitral valve disease are:
Double density behind the right heart border due to
left atrial enlargement.
Splaying of the carina by the large left atrium.
Oesophagus displaced to the right.
23b
48
Further management
Cardiac referral with a view to echocardiographic
assessment is required. Treatment involves drug therapy
for arrhythmias (atrial fibrillation AF) and to improve
cardiac function. Surgical intervention includes
percutaneous valve balloon dilatation (high recurrence
rates), valvotomy and valve replacement.
23c
Chest Imaging
CASE 24
Case 24
24
History
A 70-year-old male was referred for
further investigation following initial
imaging showing a right lower lobe
mass lesion.
49
Answer 24
Chest Imaging
ANSWER 24
Observations (24)
These PET scan images from a PET CT demonstrate a
large right lower lobe highly FDG (18 fluoro-2-deoxyglucose) avid lesion. There is a smaller left upper lobe FDG
avid lesion. There is also right hilar uptake as well as uptake
in the subcarinal region. Uptake in the region of the
oesophagus is also demonstrated. There is no FDG avid
lesion in liver or adrenals. No bony lesions are
demonstrated.
Diagnosis
Metastatic right lower lobe bronchogenic carcinoma.
Differential diagnosis
The left upper lobe lesion represents either metastases or a
synchronous lesion.
Discussion
PET scanning relies on increased uptake of FDG in cell
populations with higher metabolic turnover. The main
application is oncological imaging; other, less utilized
applications include CNS and cardiac imaging. It is essential
that PET scans are compared with cross-sectional imaging
if no PET CT scan has been performed. Assessing only
PET images alone can lead to diagnostic errors, mainly
incorrect staging of malignant disease. The CT images (not
shown) of this PET/CT scan demonstrated a right sided
pleural effusion that turned out to be malignant. Pleural
effusions do not demonstrate increased FDG activity.
Among other areas, normal FDG uptake is
demonstrated in the brain, heart, salivary glands, liver,
spleen as well as upper renal tract and it is also excreted in
the urine. Normal bowel uptake is also often demonstrated.
Pitfalls include increased FDG uptake in fat (brown fatty
tissue); this can simulate malignant nodal disease. In the
current study, the increased oesophageal uptake is due to
a coexisting reflux oesophagitis.
Practical tips
In the UK, PET scanning is used mainly as a staging
tool. Neurological and cardiac applications are not
utilized widely. Among others, PET is used for initial
staging and restaging of bronchogenic or oesophageal
carcinoma.
Cancer networks are increasingly utilizing PET prior
to planning for curative surgery. A growing
application is the assessment of solitary nodules. This
is particularly useful in central lesions for which
histological confirmation is more challenging and the
complication rate is increased.
A well documented pitfall is a false negative scan for
small lung nodules or metastases. Lesions measuring
less than 78 mm do have a higher false negative rate.
Lymphoma staging is also widely undertaken. This is
very useful for assessment of activity in residual
lymphoma masses and also for assessment of early
response to chemotherapy. Inflammatory or infected
nodal mediastinal masses (histoplasmosis) can also
give rise to false positive scans. Correlation with crosssectional imaging is important in all cases where FDG
imaging is undertaken.
Further management
PET CT results should be discussed within a multidisciplinary team with the purpose of deciding whether the
patient would be a candidate for surgical disease clearance.
24
50
Chest Imaging
CASE 25
Cases 25, 26
25a
History
A 45-year-old female, previously
resident in the USA, presented for a
pre-employment chest radiograph.
CASE 26
26a
History
A 24-year-old male presented with
dysphagia.
51
Answer 25
Chest Imaging
ANSWER 25
Observations (25a)
This frontal chest radiograph demonstrates widespread 13
mm diameter miliary nodules seen throughout both lungs
with no zonal predominance. The miliary nodules are of
calcific density. Popcorn calcification of the left hilar lymph
nodes is seen. In addition, there is amorphous calcification
seen under the left hemidiaphragm, which is likely to be in
the spleen.
Diagnosis
Histoplasmosis.
Differential diagnosis
For increased density miliary opacities:
Miliary metastases.
Pneumoconiosis silicosis, siderosis, baritosis.
Varicella-zoster (25b).
Haemosiderosis due to chronic pulmonary venous
hypertension, pulmonary haemorrhage, or idiopathic.
Histoplasmosis.
Practical tips
In cases where there are multiple radiological findings,
consider the differential diagnosis list for each finding and
identify an overlapping diagnosis (easier said than done in
a viva situation!).
Further management
For popcorn calcification of lymph nodes:
Sarcoidosis.
Silicosis.
Histoplasmosis.
Coal workers pneumoconiosis (CWP).
Lymphoma post radiotherapy.
For splenic calcification:
Tuberculosis.
Histoplasmosis.
Infarcts secondary to sickle cell disease.
Hydatid cysts.
Haematoma.
Discussion
Histo plasma capsulatum is a fungus usually found in
temperate climates and most commonly in the northern
USA. Infection is by inhalation of air borne fungal spores.
These germinate in the alveoli and then spread via the
pulmonary lymphatics to the hilar/mediastinal lymph nodes
25b
52
Further reading
Brown K, Mund DF, Aberle DR, et al. (1994).
Intrathoracic calcifications: radiographic features and
differential diagnoses. Radio Graphics 14: 12471261.
Wheat LJ, Wass J, Norton J (1984). Cavitary
histoplasmosis occurring during two large urban
outbreaks. Analysis of clinical, epidemiologic,
roentgenographic, and laboratory features. Medicine
(Baltimore) 63(4): 201209.
Wheat LJ, Connolly-Stringfield PA, Baker RL (1990).
Disseminated histoplasmosis in the acquired immune
deficiency syndrome: clinical findings, diagnosis and
treatment, and review of the literature. Medicine
(Baltimore) 69(6): 361.
Answer 26
Chest Imaging
Case 27
ANSWER 26
Observations (26a)
Practical tips
Further management
Diagnosis
Discussion
Diagnosis can be confirmed with arterial phase contrast
enhanced CT chest (26b). Right sided aortic arch can be
associated with several congenital cardiac abnormalities but
it can also be seen in patients without cardiac abnormalities. The latter group of patients usually have a right
sided aortic arch with an aberrant left subclavian artery
(arising as the most distal branch of the aortic arch), which
passes behind the oesophagus. This can be seen on a
barium swallow examination as a posterior indentation in
the barium column of the mid oesophagus. Patients with
right sided aortic arch with mirror image branching, such
that the left subclavian arises as a branch of the first vessel
of the aortic arch, are the group usually associated with
cyanotic heart disease. The aorta descends in the right
posterior mediastinum (although in a small proportion,
<5%, this is on the left).
26b
CASE 27
27a
History
A 34-year-old smoker presents with
progressively worsening shortness of
breath.
53
Answer 27
Chest Imaging
ANSWER 27
Observations (27a)
The chest radiograph shows bilateral thick and thin walled
cysts throughout both lungs with preservation of lung
volumes. Some small nodules are also seen particularly
within the right upper zone. No pleural effusion or
pneumothorax is seen. No bony abnormality or soft tissue
nodules to suggest neurofibromatosis. In spite of the
patients sex, the widespread distribution and nodularity
would make Langerhans cell histiocytosis the most likely
diagnosis.
Diagnosis
Langerhans cell histiocytosis.
Differential diagnosis
For cystic lung disease with normal or increased lung
volumes:
Lymphangioleiomyomatosis affects women in
2nd6th decades. There are multiple cysts seen
throughout the lungs of relatively uniform size (~5
mm) and shape, with no nodule formation.
Commonly associated with chylous pleural effusions
and recurrent pneumothoraces.
Neurofibromatosis predominantly apical cysts.
Tuberous sclerosis.
Cystic bronchiectasis.
Discussion
Langerhans cell histiocytosis is a multisystem
granulomatous disease, which occurs more commonly in
young (3rd4th decades) adult males, and has an
association with cigarette smoking. Pulmonary changes on
CXR involve a sequence of changes initial signs are of
nodules that progressively cavitate to result in thick and
then thin walled cyst formation. Lung volumes are usually
Practical tips
On a CXR, cystic lung disease with normal/increased lung
volumes can be differentiated by looking at patients sex
and by identifying other radiological findings:
Lymphangioleiomyomatosis occurs exclusively in
women.
Neurofibromatosis changes on a CXR include ribbon
ribs; soft tissue masses (neurofibromas) seen in
posterior mediastinum and skin.
Tuberous sclerosis is easily identified by the history
being characterized by the triad of mental retardation,
seizures and adenoma sebaceum.
Bronchiectasis produces thicker walled cysts and the
thickened airway walls may also be visible along their
lengths as tramtracking.
Further management
HRCT can be useful in the follow-up of these patients
when looking for potential complications of
aspergilloma/mycetoma infection, cavitating nodules and
pneumothoraces.
Further reading
Moore AD, Godwin JD, Muller NL, et al. (1989).
Pulmonary histiocytosis X: comparison of
radiographic and CT findings. Radio lo gy 172:
249254.
27b
54
Chest Imaging
CASE 28
Cases 28, 29
28
History
A 29-year-old male presented with
intermittent pain in both arms. Images
28b and 28c were taken just 1 minute
apart what has happened between
them?
CASE 29
29a
History
A 65-year-old male presented with
progressively worsening shortness of
breath.
29b
55
Answers 28, 29
Chest Imaging
ANSWER 28
Observations (28a, b, c)
Discussion
Diagnosis
Practical tips
Differential diagnosis
Further management
US is useful as a dynamic test for assessing arterial
Doppler signal with the arm in a neutral and elevated
position.
CT/MRI can be useful in identifying the cause of
compression if not apparent on plain radiography.
ANSWER 29
Observations (29a, 29b)
Two axial CT images of the chest show features of
cardiomegaly, bilateral pleural effusions and patchy ground
glass opacity with smooth interlobular septal thickening.
This combination of imaging findings would fit with a
diagnosis of pulmonary oedema.
Diagnosis
Discussion
Differential diagnosis
For ground glass opacity:
Pulmonary oedema.
Infection.
Haemorrhage.
Interstitial pneumonias.
Extrinsic allergic alveolitis.
Alveolar proteinosis.
Sarcoidosis.
Focal areas of ground glass alveolar cell
carcinoma/lymphoma.
56
Answer 29
Chest Imaging
CASE 30
Case 30
Practical tips
A combination of cardiomegaly, pleural effusion and
airspace opacity suggests cardiac failure with pulmonary
oedema.
Further management
Medical management with CXR radiological follow-up as
appropriate.
30a
History
A 65-year-old male was referred for a
cardiac MRI to assess cardiac viability.
30b
57
Answer 30
Chest Imaging
ANSWER 30
Observations (30a, 30b)
The first image (30a) is a short axis scan through the left
ventricle during the first pass of contrast. There is no
contrast enhancement of the thinned left ventricular septal
and anterior walls. The visualized posterior, lateral and
inferior walls show normal enhancement and are of normal
thickness. The second image (30b) is a delayed four
chamber view showing delayed, prolonged enhancement
of the septal, apical and anterolateral wall of the left
ventricle. These appearances are of an extensive left
ventricular infarct with no evidence that involved areas are
viable.
Diagnosis
Left ventricular infarct involving the septal/apical/
anterolateral walls.
Discussion
Cardiac MRI has an expanding role and current uses
include assessment of:
Cardiac viability prior to revascularization.
Cardiac congenital heart defect.
Cardiac tumours.
Pericardial disease.
Cardiomyopathies.
Practical tips
Cardiac MRI is a dynamic test that requires assessment of
cine images to make a subjective and objective assessment
of left ventricular function (ejection fraction).
Further management
Assessing cardiac viability post myocardial infarction is
important since revascularization of live tissue reduces
morbidity and mortality. Previously cardiac perfusion was
assessed by cardiac nuclear medicine (MIBG metaiodobenzylguanidine [scintiscan]) stress testing but there is
now an increased role for cardiac MRI.
30b
58
Chest Imaging
CASE 31
Cases 31, 32
31a
History
A 45-year-old female patient presented
with chest pain.
CASE 32
32a
History
A 24-year-old male presented with
chest pain after minor trauma.
59
Answer 31
Chest Imaging
ANSWER 31
Observations (31a)
Discussion
Diagnosis
Mastectomy and sclerotic bone metastases.
Differential diagnosis
For causes of unilateral hypertransradiancy:
Chest wall abnormality mastectomy, pectoral muscle
atrophy (polio) or absence (Polands syndrome).
Pleural abnormality pneumothorax.
Lung abnormality SwyerJames syndrome
(consequence of bronchiolitis as a child resulting in a
hypoplastic lung with air trapping on expiration),
emphysema, bullae, pulmonary embolus (31b).
For causes of unilateral hyperdensity:
Chest wall abnormality gynaecomastia (unilateral in
40% of cases), breast implant.
Pleural abnormality pleural effusion on supine film,
pleural thickening.
Lung abnormality unilateral pulmonary oedema
from lying on one side (31c), consolidation, lobar
collapse (especially left upper lobe).
Practical tips
In any case with a history of breast cancer, the chest
radiograph should be scrutinized for features of recurrence.
These are classical viva films for exams and also present
frequently in everyday practice. Features to look for
include:
Sclerotic/lytic bone metastases (31d).
Lung metastases.
Lymphangitis carcinomatosa.
Pleural effusion.
Axillary lymphadenopathy.
Right hemidiaphragm elevation secondary to liver
metastases.
Pulmonary pneumonitis/fibrosis from radiotherapy.
Further management
In cases where clinical history and examination do not
reveal an obvious cause for the relative differences in
chest lucency CT chest would be appropriate.
Isotope bone scan may identify distant bone
metastases.
31b
31c
60
Answers 31, 32
Chest Imaging
31d
ANSWER 32
Observations (32a)
Discussion
Diagnosis
Inferior rib notching due to coarctation of the aorta.
32b
Differential diagnosis
For inferior rib notching:
Arterial:
Coarctation of the aorta.
Subclavian obstruction after BlalockTaussig shunt
for tetralogy of Fallot.
Venous: SVC obstruction.
Arteriovenous malformations (AVM).
Neurogenic, neurofibromatosis.
For superior rib notching:
Rheumatoid arthritis, scleroderma and systemic lupus
erythematosus (SLE).
Hyperparathyroidism.
Neurofibromatosis.
Marfans syndrome.
Restrictive lung disease.
61
Answer 32
Chest Imaging
Further management
Surgical treatment for coarctation of the aorta involves
resection and end to end anastomosis, prosthetic patch
graft, subclavian flap aortoplasty or balloon angioplasty.
Practical tips
When suspected from plain films and clinical findings,
MR or CT angiography has now largely replaced
conventional angiography as the next investigation of
choice (32c).
32c
62
Chest Imaging
CASE 33
Cases 33, 34
33a
History
A 38-year-old man was being
investigated for transient neurological
episodes.
CASE 34
34
History
A 52-year-old woman with oesophageal
cancer presented complaining of chest
pain.
63
Answers 33, 34
Chest Imaging
ANSWER 33
Observations (33a)
Further management
Further reading
Coley SC, Jackson JE (1998). Pulmonary arteriovenous
malformations. Clinical Radio lo gy 53(6): 396404.
Pick A, Deschamps C, Stanson AW (1999). Pulmonary
arteriovenous fistula: presentation, diagnosis, and
treatment. Wo rld Jo urnal o f Surgery 23(11):
11181122.
Diagnosis
Pulmonary arteriovenous malformation (AVM).
Differential diagnosis
Single or multiple pulmonary nodules from other causes.
33b
Discussion
Pulmonary AVMs are abnormal vascular communications
between pulmonary arteries and veins (95%) or systemic
arteries and pulmonary veins. Most commonly, they are of
the simple type, with a single artery feeding a focal
aneurysmal segment and a single draining vein. Complex
lesions have more than one artery and/or vein. Figure 33b
is a single angiographic image that demonstrates the large
feeding vessel to a solitary AVM.
Multiple pulmonary AVMs may be associated with
OslerWeberRendu syndrome. They are usually asymptomatic until the 3rd4th decade when they can present
with local effects haemoptysis, dyspnoea on exertion and
cyanosis with clubbing (due to right to left shunt); or with
distal effects cerebrovascular accident (CVA) or brain
abscess due to paradoxical emboli. Lesions enlarge with
age.
Practical tips
The finger in glove appearance from mucoid impaction
of central airways in allergic bronchopulmonary aspergillosis can look similar in some ways to the vessels
supplying an AVM. However, there is a nodule at the end
of these vessels in AVM.
ANSWER 34
Observations (34)
Differential diagnosis
Diagnosis
Pneumomediastinum
oesophageal cancer.
64
from
perforation
of
stented
Answer 34
Chest Imaging
Discussion
Pneumomediastinum is an uncommon condition that is
usually asymptomatic but can present with neck or chest
pain. In itself it rarely leads to any complications but it can
be a useful diagnostic sign for an underlying medical
condition that does need treatment. Although a rare
condition in adults, it is seen in children and most
commonly in neonates.
Radiological features include:
Thin line following the mediastinal contours, as in
this case. This line represents the pleura, lifted away
from the mediastinal soft tissue by air.
Streaky air lucencies in the mediastinum.
Continuous diaphragm sign where lucency is seen
behind the heart, connecting the two domes of the
diaphragm.
Case 35
Further management
Chest CT after the patient has drunk some water-soluble
contrast, or a water-soluble contrast swallow, can confirm
an oesophageal tear and leak and help to identify the site.
Further reading
Gerazounis M, Athanassiadi K, Kalantzi N, Moustardas
M (2003). Spontaneous pneumomediastinum: a rare
benign entity. Jo urnal o f Tho racic and Cardio vascular
Surgery 126(3): 774776.
Practical tips
Assess the ribs for any sign of trauma.
Assess the lung fields for a lesion that might have
warranted bronchoscopic/surgical investigation.
Look for air under the diaphragm to indicate
pneumoperitoneum.
CASE 35
35a
History
A 50-year-old male presented to A&E
with recurrent acute-on-chronic
dyspnoea.
65
Answer 35
Chest Imaging
ANSWER 35
Observations (35a)
There is a large area of increased lucency in the right mid
and upper zone with no visible lung markings. There is no
visible lung edge, however, to suggest this is a pneumothorax. Moreover, there is crowding of vessels in the lower
zone. The appearances are likely to indicate a large upper
lobe bulla. There are no focal pulmonary opacities to
indicate superadded infection. Comparison with any
available old films should help confirm this interpretation.
A general reduction in density in the left upper zone
suggests that similar pathology is developing here too.
Diagnosis
Large right sided bulla.
Discussion
A bulla is a large dilated airspace within the lung with a wall
less than 1 mm thick. They are usually produced by alveolar
destruction in emphysema. Impaired ventilation of the rest
of the lung can result in dyspnoea, as well as that due to
the background chronic lung disease.
Confusion can arise when the absence of lung markings
leads to the erroneous diagnosis of pneumothorax. This
Practical tips
A pneumothorax leads to two findings: a visible lung edge
and hypodensity with absent lung markings lateral to this
(35b). A bulla has absent lung markings but not the
discrete lung edge. Conversely, skin folds (seen most
frequently in babies and the elderly) can produce a pseudo
lung edge but there will be lung markings lateral to it
(35c).
Further management
If diagnostic uncertainty continues after expert review of
the films, then occasionally CT of the thorax may be
needed to differentiate bullae from pneumothorax.
35b
35c
66
Chest Imaging
Case 36
CASE 36
History
A 15-year-old male with diabetes presented
with recurrent chest infections.
36b
36a
36c
67
Answer 36
Chest Imaging
ANSWER 36
Observations (36a, 36b, 36c)
This frontal chest radiograph (36a) demonstrates widespread, fairly symmetrical lung parenchymal abnormality
that is central in distribution and characterized by bronchial
wall thickening and cystic bronchiectatic change. Some
larger soft tissue density nodules are seen in the lower
zones, which likely represent mucous plugs. Bilateral
lobulated hilar enlargement is seen with the right sided
lymphadenopathy being more evident. Appearances are of
cystic fibrosis.
Chest radiograph (36b) from the same patient taken at
a later date demonstrates more advanced disease with more
mucous plugging and hyperinflated lungs secondary to air
trapping. Peribronchial cuffing and thickened nontapering
bronchi are evident. A right subclavian central line is noted,
presumably for the administration of IV antibiotics.
A CT image (36c) of the chest on lung windows shows
typical features of CF with cylindrical bronchiectasis and a
central distribution, peribronchial cuffing, mucous plugging
and focal atelectasis. It also shows the most common
complication of a pneumothorax on the left side.
Diagnosis
Cystic fibrosis (CF).
Discussion
Cystic fibrosis is an autosomal recessive multisystem
condition that is characterized by exocrine gland
dysfunction due to mucous plugging arising secondary to a
fault in cell chloride transport. The condition affects whites
with a geographical distribution affecting Europeans and
Ashkenazi Jews. Diagnosis is usually made in children, with
the majority being diagnosed within the first year of life
with the clinical presentation of meconium ileus and
respiratory symptoms. Pulmonary complications are the
predominant cause of death and survival is limited to
~3040 years.
36c
68
Practical tips
Typical presentation is of widespread pulmonary
disease in a young patient.
Tunnelled central lines in patients are used for long
term drug treatment with antibiotics or
chemotherapy. Again this is a clue to the underlying
diagnosis.
Look for complications of CF pneumothoraces and
secondary infections.
Though not a common site, HPOA can occur in the
humerus and may thus be visible on the edge of the
film.
Further management
Follow-up in these patients is best performed with HRCT,
which can answer the important questions when lung
transplant is considered is there coexistent Aspergillus
infection? Are there complicating features, e.g. pneumothoraces?
36d
Chest Imaging
Case 37
CASE 37
History
A 34-year-old IV drug user presented with cough and
severe shortness of breath. He is noted to be significantly
hypoxic on presentation. This series of chest radiographs
were taken at presentation, day 3 and day 7.
37a
37b
37c
69
Answer 37
Chest Imaging
ANSWER 37
Observations (37a, 37b, 37c)
The first chest film taken at presentation (37a) shows no
obvious radiological abnormality. The next radiograph
from 3 days later (37b) shows bilateral mid and lower zone
reticular/granular interstitial infiltrate with no evidence of
volume loss. The third film from 7 days after presentation
(37c) shows bilateral consolidative change affecting both
lungs. There is a pneumothorax on the left with subtotal
collapse of the left lung. Surgical emphysema is noted.
It is notable that the patient was initially very
symptomatic with a relatively normal chest film and then
showed rapid pulmonary changes over several days. The
history of IV drug abuse raises the possibility of background
HIV infection and the sequence of radiological appearances
is typical for Pneumo cystis carinii pneumonia.
Practical tips
A strong index of suspicion for PCP should be maintained
when an immunocompromised patient presents with
dyspnoea. As in this case, symptoms can be out of
proportion to the initial radiographic changes.
Diagnosis
Pneumo cystis carinii pneumonia (PCP).
Further management
Discussion
70
Further reading
Kuhlman JE, Kavuru M, Fishman EK, Siegelman SS
(1990). Pneumo cystis carinii pneumonia: spectrum of
parenchymal CT findings. Radio lo gy 175: 711714.
Chapter 2
ABDOMINAL IMAGING
General assessment
Rapidly assess the quality of the film, ensuring that there
is adequate coverage are the hernial orifices covered in
the patient who appears to have small bowel obstruction?
In addition, make a quick assessment of the film to exclude
two important diagnoses that are surgical emergencies and
will require immediate management:
Perforation.
Toxic megacolon.
Lines
Identify any lines that are present, e.g. postsurgical drains,
NG tubes, urinary catheters and peritoneal dialysis
catheters. The presence of peritoneal dialysis catheters or
postsurgical drains may offer a simple explanation for free
intraperitoneal gas.
Calcification
Look at the rest of the film for calcified densities such as
gallstones (only 510% visible on plain radiographs) and
renal tract calculi (8085% visible on plain radiographs).
Common incidental calcific opacities include mesenteric
nodes, phleboliths, vascular calcification and uterine
fibroids. Calcification within the solid organs may be more
significant however. Unusual calcified opacities may allow
for a specific diagnosis such as a pelvic dermoid.
Gas pattern
Differentiating small from large bowel is very difficult in
young children and one can usually only say whether a
problem is in the proximal or distal bowel. In adults,
features used to distinguish the two include position in the
abdomen; diameter (large bowel <5 cm, small bowel <3
cm); valvulae conniventes traverse the whole width of small
bowel but this is not so with the colonic haustrations; solid
faeces only seen in colon.
The range of normal bowel gas patterns is rather wide,
but from experience, one should quickly know whether
the amount and distribution of bowel gas are very
abnormal. Unusually shaped collections of gas (e.g.
triangular) should raise suspicion of gas outside the GI
tract and lead you to examine the area very closely. Check
carefully for gas in areas of the abdomen where it is not
normally seen, e.g. over the liver (either as pockets of gas
or within the biliary tree) or in the retroperitoneum. Dont
Bones
Assess the bones of the vertebral column and pelvis for
incidental pathology or findings that might be relevant to
intra-abdominal disease such as sacroiliac joint changes
associated with inflammatory bowel disease.
ABDOMINAL CT
The first question to ask yourself when looking at an
abdominal CT is what type of contrast has the patient been
given, i.e. oral/IV/both and during what phase has
imaging been carried out. The typical phase for abdominal
71
Abdominal Imaging
72
Abdominal Imaging
CASE 38
Cases 38, 39
38a
History
A 53-year-old male presented with a
history of gradually progressive
dysphagia.
CASE 39
39
History
A 78-year-old female presented with
rectal bleeding.
73
Answer 38
Abdominal Imaging
ANSWER 38
Observations (38a)
Practical tips
Diagnosis
Further reading
Differential diagnosis
Further management
Gastroenterology referral with a view to direct visualization
and confirmation of diagnosis with endoscopy.
38b
Discussion
Peptic strictures have this typical appearance of short (14
cm), smooth, tapered, concentric narrowing in the lower
oesophagus. Associated radiological findings include
intramural pseudodiverticulosis (38b) and feline oesophagus (so called because this is the normal appearance in
cats). Longitudinal scarring can cause fixed transverse folds
but these can be differentiated from feline oesophagus
since they are only seen in the region of the stricture and
do not extend more than half way across the oesophagus,
giving a step ladder appearance.
38b Contrast barium swallow shows flask shaped
outpouchings with a narrow neck of intramural
pseudodiverticulosis.
74
Answer 39
Abdominal Imaging
Case 40
ANSWER 39
Observations (39)
Single image from a mesenteric angiogram examination
shows an abnormal cluster of vessels and contrast blush
in the caecum.
Diagnosis
Angiodysplasia.
Differential diagnosis
Of lower GI haemorrhage:
Diverticular disease.
Colonic carcinoma.
Colonic angiodysplasia.
Inflammatory colitis.
Mesenteric varices.
Discussion
Angiodysplasia is the most common cause of occult
bleeding in the large bowel, predominantly affecting the
elderly population. The condition is characterized by
vascular ectasia of the colonic circulation, most commonly
affecting the caecum and ascending colon. The condition
leads to chronic low-grade blood loss but can also lead to
episodes of severe lower GI bleeding. There is an association with valvular heart disease, specifically aortic stenosis.
CASE 40
Practical tips
CT is excellent at identifying the bleeding point when
there is active GI bleeding. Always perform a pre-contrast
scan prior to the arterial phase scan so that highcontrast intraluminal blood can be differentiated from
high-contrast bowel food content/debris.
Further management
Surgical resection is the definitive treatment when
endoscopic treatments have not controlled bleeding.
40a
History
A 35-year-old farmer presented with
mild ache in the right upper abdomen
for several months.
75
Answer 40
Abdominal Imaging
ANSWER 40
Observations (40a)
There is a large, well defined lesion in the right upper
quadrant, which has thin, curvilinear calcification of its wall.
This is projected over the liver and is probably intrahepatic,
though a calcified gallbladder cannot be excluded from this
film. This is a solitary lesion with no other abnormality
seen. Given the appearances and patients young age and
occupation, a hydatid cyst of the liver is most likely. Further
imaging with CT would help confirm the location of the
lesion and the likely diagnosis. Serological tests for hydatid
disease should also be undertaken.
Practical tips
Diagnosis
Discussion
Further management
Hydatid disease.
Differential diagnosis
76
Further reading
Pedrosa I, Saz A, Arrazola J, et al. (2000). Hydatid
disease: radiologic and pathologic features and
complications. Radio Graphics 20: 795817.
Polat P, Kantarci M, Alper F, et al. (2003). Hydatid
disease from head to toe. Radio Graphics 23:
475494.
40b
Abdominal Imaging
CASE 41
Case 41
41a
History
A 67-year-old, overweight female
patient, with no past medical history,
presented with vague abdominal pain,
nausea and vomiting.
41b
77
Answer 41
Abdominal Imaging
ANSWER 41
Observations (41a, 41b)
AP abdominal radiograph shows distended loops of gasfilled small bowel but absent colonic gas. Together with
the clinical history, appearances are consistent with small
bowel obstruction. There is no evidence of free gas on
these films but on the second image there is an abnormal
collection of air over the central liver that has a somewhat
linear/branching configuration. This is consistent with air
in the biliary tree. In the right side of pelvis, there is a
round opacity showing peripheral calcification this is likely
to indicate an obstructing gallstone.
Diagnosis
Gallstone ileus.
Discussion
Gallstone ileus is relatively rare, accounting for 12% of all
mechanical obstructions (though more in the elderly). The
most common scenario is of a stone eroding through from
gallbladder to duodenum the cholecystoduodenal fistula
leads to pneumobilia and the stone then impacts in the
small bowel. The fistula can also be from the common duct,
and can extend to the colon or stomach instead of the small
bowel.
Occasionally, the diagnosis can be made on plain films
with Riglers triad of small bowel obstruction, pneumobilia
and ectopic gallstones. Often, however, the gallstone is not
seen on plain film since the stones frequently have a
predominant composition of cholesterol with little
41c
78
Practical tips
Always check for air in the biliary tree on the small
bowel obstruction abdominal film.
Tiny locules of air in the biliary tree tend to be
centrally located in the liver (41d) compared with
portal vein gas, which is seen in the periphery.
Biliary tree gas can also be seen as a normal finding in
patients who have had a previous sphincterotomy or
following a recent ERCP (endoscopic retrograde
cholangiopancreatography).
Further management
Mechanical small bowel obstruction is a surgical
emergency.
Further reading
Gurleyik G, Gurleyik E (2001). Gallstone ileus:
demographic and clinical criteria supporting
preoperative diagnosis. Ulus Travma Derg 7(1):
3234.
Pangan JC, Estrada R, Rosales R (1984).
Cholecystoduodenocolic fistula with recurrent
gallstone ileus. Archives o f Surgery 119: 12011203.
41d
Abdominal Imaging
CASE 42
Cases 42, 43
42
History
A 68-year-old male is admitted with
hepatic encephalopathy.
CASE 43
43
History
An asymptomatic 22-year-old male
presented with deteriorating renal
function.
79
Answers 42, 43
Abdominal Imaging
ANSWER 42
Observations (42)
Image from a double contrast barium meal examination
shows multiple serpiginous filling defects in the lower
oesophagus. Normal appearances of the gastric fundus are
observed. Appearances are consistent with oesophageal
varices and the distribution suggests that these are uphill.
Diagnosis
Oesophageal varices.
Differential diagnosis
For oesophageal varices:
Varicoid carcinoma of oesophagus.
For gastric varices (i.e. causes of thickened gastric folds):
Hypertrophic gastritis.
Mntriers disease.
Lymphoma.
Splenic vein thrombosis.
Discussion
Oesophageal varices have a very typical appearance on
contrast swallow examination of dilated, smooth,
serpiginous filling defects. Varices collapse in the erect
position and are best imaged with the patient prone. There
are two types:
Uphill varices (found in the lower oesophagus); these
are characterized by collateral blood flow from the
portal vein via the azygous vein to the superior vena
cava (SVC). These arise due to liver cirrhosis and due
Practical tips
Best images are obtained with the patient in a prone
position.
Further investigation with an ultrasound of the
abdomen should be advised to look for cirrhosis and
portal hypertension.
Further management
Treatment is aimed at controlling portal hypertension with
medical and surgical (transjugular intrahepatic
portosystemic shunt TIPS) means. Treatment of bleeding
varices and preemptive treatment of nonbleeding varices is
achieved with endoscopic banding and sclerotherapy.
ANSWER 43
Observations (43)
This plain abdominal radiograph shows multiple small foci
of calcification over both renal areas in the region of the
renal medulla rather than renal cortex. No stones are seen
elsewhere along the course of the renal tracts.
Diagnosis
Renal medullary nephrocalcinosis.
Discussion
Medullary nephrocalcinosis represents calcification in the
distal convoluted tubules, i.e. in the renal pyramids. There
are many causes and the underlying pathology can rarely
be determined on a plain radiograph clinical history is far
more important here.
The causes are:
Renal tubular acidosis (RTA).
Endocrine causes hyperparathyroidism,
hyperthyroidism, Cushings.
Medullary sponge kidney.
Idiopathic hypercalcuria.
80
Practical tips
The most common causes of symmetrical medullary
nephrocalcinosis are hyperparathyroidism and RTA.
The most common cause of asymmetrical medullary
nephrocalcinosis is medullary sponge kidney.
Further management
Underlying cause must be identified particularly treatable
causes.
Further reading
Dyer RB, Chen MY, Zagoria RJ (1998). Abnormal
calcifications in the urinary tract. Radio Graphics 18:
14051424.
Abdominal Imaging
CASE 44
Cases 44, 45
44
History
A 34-year-old male presented with
nausea and vomiting.
CASE 45
45a
History
A 68-year-old male presented with
postprandial bloating.
81
Answers 44, 45
Abdominal Imaging
ANSWER 44
Observations (44)
This is a single AP image from a double contrast small
bowel barium examination. There is focal, eccentric
narrowing of the second part of the duodenum, with
predominant notching of the lateral wall. Appearances of
the duodenum superior and inferior to this are completely
normal.
Diagnosis
Annular pancreas.
Differential diagnosis
For annular pancreas:
Sphincter of Oddi oedema (secondary to impacted
stone or pancreatitis)/carcinoma usually produces an
eccentric lesion but this is predominantly medially
located.
Duodenal adenocarcinoma usually presents with an
annular concentric lesion with shouldering and
ulceration. There is an association with Gardners
syndrome and coeliac disease.
Discussion
Annular pancreas is a disorder characterized by failure of
rotation of the ventral bud of the pancreas resulting in
pancreatic tissue encircling the duodenum. The second part
of the duodenum is involved in 85% of cases. Usually
patients are asymptomatic, but the condition can present
at any age, with 48% of cases presenting in adulthood.
There is an association with other congenital abnormalities
when the condition presents in childhood tracheooesophageal atresia, duodenal atresia, imperforate anus,
Downs syndrome.
Practical tips
Carefully examine the film for gallstones or small bowel
features of coeliac disease (small bowel dilatation,
flocculation of contrast, featureless smooth small bowel
lumen/folds, jejunization of ileal loops and poor
peristalsis) to suggest another diagnosis.
Further management
CT will confirm pancreatic tissue encircling the
duodenum.
ERCP (endoscopic retrograde
cholangiopancreatography) or MRCP (magnetic
resonance cholangiopancreatography) shows a
normally located main pancreatic duct in the body of
the pancreas, and a small duct in the head of the
pancreas encircling the duodenum.
Further reading
Rizzo RJ, Szucs RA, Turner MA (1995). Congenital
abnormalities of the pancreas and biliary tree in
adults. Radio Graphics 15(1): 4968.
ANSWER 45
Observations (45a)
Discussion
Diagnosis
Primary sclerosing cholangitis (PSC).
Differential diagnosis
For PSC:
Sclerosing cholangiocarcinoma.
Acute ascending cholangitis.
Bile duct carcinoma this can rarely involve the biliary
system in a diffuse manner producing multiple tumour
strictures.
82
Answer 45
Abdominal Imaging
Case 46
45b
Practical tips
MRCP is now the noninvasive diagnostic investigation of
choice.
Further management
The only curative treatment for this condition is liver
transplantation. Medical palliative care involves treatment
of the symptoms of cirrhosis, portal hypertension, chronic
cholestasis (pruritus and malabsorption) and ductal
complications such as strictures and ascending cholangitis.
A multidisciplinary approach is therefore adopted requiring
hepatologists, transplant surgeons and interventional
radiologists.
45b Single image from an ERCP examination
showing multiple strictures with poststenotic
dilatation giving a beaded appearance.
CASE 46
46a
History
A 67-year-old male presented with
abdominal pain and vomiting.
83
Answer 46
Abdominal Imaging
ANSWER 46
Observations (46a)
This plain abdominal radiograph shows a large, ahaustral
gas-filled viscus arising from the left side of the pelvis and
extending into the upper abdomen. The loop is projected
over the left side of pelvis and descending colon with its
apex under the left hemidiaphragm. The medial walls of
the loop form a summation line. There are several dilated
loops of descending colon evident with absence of gas in
the rectum. The features are typical of sigmoid volvulus and
there is no free intraperitoneal gas seen to indicate
perforation.
Diagnosis
Sigmoid volvulus.
Differential diagnosis
For large bowel obstruction:
Colonic malignancy.
Inflammatory strictures: Crohns, ischaemia,
diverticulitis.
Volvulus.
Infectious processes: TB, amoebiasis.
Extrinsic lesions: abscess, bladder/prostate/uterine
tumour, endometriosis.
Further management
Urgent surgical referral with a view to insertion of a flatus
tube to decompress the bowel.
Further reading
Burrell HC, Baker DM, Wardrop P, Evans AJ (1994).
Significant plain film findings in sigmoid volvulus.
Clinical Radio lo gy 49: 317319.
Discussion
Volvulus account for ~10% of large bowel obstructions in
the UK, the most common type being sigmoid volvulus.
This occurs more commonly in the elderly. The twisting of
the sigmoid colon on its mesenteric axis is usually a chronic
problem with superimposed acute episodes, and represents
a closed loop obstruction. Radiologically, the features are
of large bowel obstruction with a markedly dilated loop of
colon seen arising from the left iliac fossa. The volvulus is
characterized by an ahaustral inverted U-shaped loop of
colon. The medial walls produce a summation line and
together with the lines of the lateral walls create the classic
coffee bean appearance. Several radiological features have
been documented as typical, though the most specific are:
Apex of the loop under the left hemidiaphragm.
Inferior convergence of the loop in the left side of the
pelvis the main axis of the loop therefore extends
from left iliac fossa towards right upper quadrant.
Left flank overlap sign loop overlaps descending
colon.
Medial wall summation line.
46b
Practical tips
Caecal volvulus (46b) can sometimes be a confusing
differential. It represents twisting just above the ileocaecal
84
Abdominal Imaging
CASE 47
Cases 47, 48
47a
History
A 35-year-old female presented with
abdominal pain and vomiting.
CASE 48
48a
History
A 38-year-old woman underwent
contrast enhanced CT for further
evaluation of a lesion noted on
ultrasound.
(see page 88 fo r case answer)
85
Answer 47
Abdominal Imaging
ANSWER 47
Observations (47a)
Multiple dilated loops of gas-filled small bowel that
measure more than 3 cm in diameter are seen within the
central abdomen. No gas is seen within the large bowel and
appearances are consistent with small bowel obstruction.
Surgical clips are noted in the right side of pelvis along with
cholecystectomy clips in the right upper quadrant.
Adhesions are therefore the most likely cause of the
obstruction.
Diagnosis
Practical tips
Differential diagnosis
For small bowel obstruction:
Adhesions account for up to 60% of small bowel
obstructions.
Hernia.
Gallstone ileus.
Small bowel or caecal malignancy.
Intussusception.
Malrotation and volvulus.
Discussion
Small bowel obstruction can have a varied presentation on
plain abdominal radiography. The classical appearance is of
central abdominal small bowel loops dilated to >3 cm in
diameter with a paucity of gas in the large bowel. Other
appearances can be of:
String of beads sign due to small air-fluid levels in
fluid-filled obstructed loops of small bowel (47b).
Absence of gas in the small bowel due to complete
obstruction and complete fluid filling of loops (47c).
Further management
CT is the investigation of choice for small bowel
obstruction and it can identify both the site and cause of
obstruction and also the complications. Mechanical small
bowel obstruction is a surgical emergency.
47b
47c
86
Answer 47
Abdominal Imaging
47d
47e
47f
47g
47h
87
Answer 48
Abdominal Imaging
ANSWER 48
Observations (48a)
A large central mass lesion is demonstrated in the left
kidney. This is slightly heterogeneous but has a predominantly fatty density. Appearances are consistent with left
renal angiomyolipoma.
Diagnosis
Angiomyolipoma.
Discussion
Angiomyolipoma is a benign lesion containing fat, blood
vessels and smooth muscle. They tend to present in two
groups of patients:
Women in their 4th7th decades where lesions arise
spontaneously and tend to be so litary and unilateral.
Young patients with tuberous sclerosis where multiple
and bilateral lesions are seen in up to 75% of patients
(48b).
They are also seen rarely in autosomal dominant polycystic
kidney disease (ADPKD) and neurofibromatosis.
Appearance on US: typical appearance is of a well
defined echobright lesion due to a high fat content
(48c). There can be a variable degree of reduced
echogenicity depending on the amount of smooth
muscle and/or haemorrhage.
48b
Practical tips
Identification of fat in a renal lesion is very specific for
angiomyolipoma.
Further management
Small lesions (<4 cm) are usually asymptomatic but lesions
>4 cm are almost always symptomatic with pain and a risk
of haemorrhage. Lesion resection or nephrectomy should
be considered in these patients. Transcatheter arterial
embolization is an alternative.
48c
88
Abdominal Imaging
Case 49
CASE 49
History
A 30-year-old male presented with
abdominal swelling over several months.
49a
49b
89
Answer 49
Abdominal Imaging
ANSWER 49
Observations (49a, 49b)
The two CT images (49a) demonstrate a large, well defined
soft tissue mass in the central abdomen. This displaces
adjacent bowel loops and most likely originates in the
mesentery.
The single image (49b) from a double contrast barium
enema examination shows multiple small, well defined
mucosal filling defects throughout the colon consistent
with widespread colonic polyposis. Multiple polyps
throughout the colon suggest an underlying genetic
condition.
Diagnosis
Familial adenomatous polyposis (FAP) with mesenteric
desmoid tumour.
Discussion
Familial adenomatous polyposis is an autosomal dominant
disease (chromosome 5) characterized by multiple colonic
adenomatous polyps that inevitably progress to colorectal
cancer within 20 years of diagnosis. Treatment involves
prophylactic total colectomy in early adult life and genetic
screening of family members from the second decade with
a view to prophylactic surgery. All patients have colonic
polyps but small bowel and gastric adenomas are also found
(periampullary cancer is the most common cause of death
once colectomy has been performed).
Other associated features include:
Desmoid tumours.
Mesenteric fibrosis.
Gastric hamartomas.
Hypertrophy of retinal pigment epithelium.
Gardner and Turcot syndromes are variants of FAP.
Gardner syndrome also includes:
Osteomas of the skull and mandible.
Dental abnormalities dentigerous cysts, odontoma,
hypercementoma, supernumerary teeth.
Soft tissue tumours such as fibroma, lipoma,
leiomyoma, neurofibroma.
Epidermal cysts.
Association with thyroid cancer.
49b
90
49b Multiple
polyps.
Practical tips
Images should be carefully inspected for a coexistent
colonic tumour as well as extracolonic malignancies.
Intussusception in adults indicates an underlying
bowel pathology, whereas in children it can be
idiopathic.
Further management
Surgical referral is required for prophylactic colectomy, as
is referral for genetic screening of relatives.
Further reading
Galiatsatos P, Foulkes WD (2006). Familial
adenomatous polyposis. American Jo urnal o f
Gastro entero lo gy 101(2): 385398.
Abdominal Imaging
Cases 50, 51
50a
CASE 50
History
A 43-year-old male presented with
abnormal liver function tests.
CASE 51
History
A 19-year-old male presented with
multiple episodes of renal colic.
51a
51b
91
Answers 50, 51
Abdominal Imaging
ANSWER 50
Observations (50a)
Practical tips
Diagnosis
Further management
Haemochromatosis.
Discussion
Primary haemochromatosis is an autosomal recessive
condition characterized by increased absorption and
deposition of iron within several organs including liver,
pancreas, heart and pituitary gland. Patients are usually
asymptomatic until the 2nd decade, then they present with
a varied clinical picture due to iron deposition in:
Skin hyperpigmentation.
Liver cirrhosis, hepatomegaly.
Pancreas diabetes.
Heart arrhythmias, dilated cardiomyopathy.
Musculoskeletal arthralgia.
Pituitary pituitary failure with signs of impotence,
testicular atrophy, hair loss.
Radiologically, imaging of the abdomen shows marked
abnormality of the liver. Accumulation of iron results in the
liver being of diffusely reduced signal on MRI. The degree
of iron deposition has been shown to correlate with the
MRI appearances. Unenhanced CT of the liver
demonstrates increased attenuation (>75 HU). Follow-up
in these patients is important due to the hepatic
complications of cirrhosis and the increased risk of
hepatocellular carcinoma.
Arthropathy of haemochromatosis is similar to that of
calcium pyrophosphate deposition disease. Chondrocalcinosis is a feature. Typically, appearances are of squaring
of the metacarpal heads due to flattening and peripheral
small, hook-like spurs (50b). Osteopenia is also common.
50b
ANSWER 51
Observations (51a, 51b)
Discussion
Diagnosis
Horseshoe kidney.
92
Answer 51
Abdominal Imaging
Case 52
51c
Practical tips
On an IVU, check for filling defects, which could
represent a renal calculus or transitional cell
carcinoma.
On US, look for a renal cell carcinoma.
On plain radiography, look for signs of bony
metastases anal stones.
Further management
Follow-up may be considered due to increased incidence
of renal malignancy.
CASE 52
52a
History
A 64-year-old male with weight loss.
93
Answer 52
Abdominal Imaging
ANSWER 52
Observations (52a)
Practical tips
Further management
Diagnosis
Stented rectal tumour with calcified liver metastases.
Differential diagnosis
For calcified liver metastases:
Mucinous adenocarcinomas colon, rectum, ovarian,
breast and stomach.
Osteosarcoma.
Endocrine pancreatic carcinoma.
Medullary carcinoma of thyroid.
Lung cancer.
Discussion
Colorectal carcinoma is the third most common cancer
diagnosed in the developed world. Rectum and sigmoid are
the most common sites of lesions. Where surgical resection
is not possible or appropriate, stents can provide
symptomatic relief and prevent obstruction.
The liver is the most common site for metastatic spread
after regional lymph nodes.
52b
94
52c
Abdominal Imaging
CASE 53
Case 53
53a
History
A 35-year-old female presented with
abdominal pain and per rectal bleeding
for 3 months.
53b
95
Answer 53
Abdominal Imaging
ANSWER 53
Observations (53a, 53b)
Plain abdominal film of adult patient shows marked wall
thickening of the transverse colon with thumb-printing.
The sigmoid loops show no such abnormalities and the
rectum contains faeces. The double contrast barium enema
film confirms extensive mucosal ulceration and a somewhat
cobblestone appearance that extends from caecum to the
descending colon. The colon distal to this is normal. The
appearances are in keeping with colitis, and sparing of the
more distal colon makes Crohns disease more likely than
ulcerative colitis. It is notable that the sacroiliac joints are
normal.
Diagnosis
Crohns disease.
Differential diagnosis
For terminal ileal disease:
TB usually has more severe involvement of the
caecum (53c). There is often evidence of pulmonary
TB.
Radiation ileitis.
Yersinia.
53c
96
For thumb-printing:
Inflammatory colitis Crohns, ulcerative colitis
(UC).
Ischaemic colitis.
Infectious colitis/pseudomembranous colitis.
Diverticulitis.
Other causes: endometriosis, amyloidosis, hereditary
angioneurotic oedema, lymphoma.
Discussion
Crohns disease is a chronic, inflammatory, granulomatous
disease that can affect any part of the bowel from
oesophagus to rectum. Small bowel is most commonly
involved and the terminal ileum is involved in over 95% of
cases (53d). Presentation is usually in the 2nd4th decades
with symptoms of abdominal pain, diarrhoea, per rectal
bleeding, weight loss and features of malabsorption.
Radiological features are:
Aphthous ulcers shallow ulcers with surrounding
oedema.
Fissures, sinuses and fistulae Crohns is the third
most common cause of fistulae after idiopathic causes
and diverticulitis. The fistulae can be between loops
53d
Answer 53
Abdominal Imaging
53e
53f
53g
97
Answer 53
Abdominal Imaging
Further management
Practical tips
Terminal ileal involvement, skip lesions and multiple
strictures are the best signs for Crohns disease. When
assessing colonic disease, remember that UC almost
always involves the rectum and has a continuous
distribution without skip lesions. However, if a UC
patient has had steroid enemas, the rectum may look
normal.
Always look for signs of complications of Crohns, i.e.
adenocarcinoma (risk increased up to 20-fold),
lymphoma, toxic megacolon, perforation, abscess,
fistulae.
Always look for signs of extraintestinal manifestations
53h
98
53i
Abdominal Imaging
CASE 54
Cases 54, 55
54
History
A 54-year-old male presented
with dyspepsia.
CASE 55
55
History
A 29-year-old male presented with
progressive dysphagia.
99
Answers 54, 55
Abdominal Imaging
ANSWER 54
Observations (54)
Discussion
Diagnosis
Erosive gastritis.
Differential diagnosis
For aphthous ulceration:
Erosive gastritis.
Crohns disease.
Barium precipitate artefacts.
For gastric fold thickening:
Erosive gastritis.
ZollingerEllison syndrome.
Crohns disease.
Malignancy lymphoma, carcinoma.
Benign reactive lymphoid hyperplasia.
Mntriers disease.
Practical tips
On the contrast examination look for features in the
oesophagus of an infective cause for the gastric appearances
or for oesophageal varices pointing to alcohol as an
underlying cause.
Further management
Gastroenterology referral with a view to endoscopy.
ANSWER 55
Observations (55)
Single image from a barium swallow examination shows a
lesion in the lower oesophagus, just superior to the gastrooesophageal junction. The lesion is well defined with a
smooth edge, indenting the oesophageal lumen. No
ulceration or infiltration is seen. Appearances suggest a
benign intramural mass, most likely a leiomyoma.
Diagnosis
Leiomyoma of the oesophagus.
Differential diagnosis
For smooth oesophageal mass lesion:
Neurofibroma.
Lipoma.
Haematoma, e.g. from instrumentation.
Duplication cyst can simulate an intramural mass.
Practical tips
Smooth, well defined, slow growing oesophageal lesions
are likely to be benign.
Discussion
This is the most common benign tumour of the
oesophagus. It is usually found in young adults, being
slightly more common in males. Growth is slow and
100
Further management
Gastroenterology referral with a view to direct visualization
with endoscopy.
Abdominal Imaging
Case 56
CASE 56
History
A 24-year-old male patient presented with dysuria.
56a
56b
101
Answer 56
Abdominal Imaging
ANSWER 56
Observations (56a, 56b)
The AP postmicturition image (56b) from an IVU series
shows bilateral dilatation of the distal ureter with a cobra
head appearance. There is a surrounding thick halo of
lucency within the bladder, representing oedema. These
appearances are of bilateral ureteroceles. The control film
(56a) demonstrates bilateral calculi in the pelvis that lie
within these ureteroceles.
Diagnosis
Bilateral ureteroceles.
Differential diagnosis
For radiolucent bladder filling defects on IVU:
Ureterocele.
Bladder tumour.
Radiolucent calculus.
56c
Discussion
A simple or orthotopic ureterocele is a congenital prolapse
of the distal ureter and its orifice into the bladder. It is
usually an incidental finding in adults and is bilateral in a
third of cases. Figure 56c shows how a ureterocele can
produce a less specific type of filling defect when the
bladder is full and Figure 56d shows the typical ultrasound
appearance. The main complication is of obstruction,
which can cause collecting system dilatation and renal
failure. There is also an increased risk of stone formation
and it is therefore imperative to check the control film in
every patient as in this case!
56d
102
Answer 56
Abdominal Imaging
Case 57
56e
Practical tips
Always remember to check the control film of an IVU.
Further management
While a small asymptomatic ureterocele may not require
treatment, recurrent urinary tract infection (UTI), calculi,
pain and obstructive uropathy are indications for surgical
intervention.
56e Single axial T2 weighted image of the pelvis
shows a pseudoureterocele secondary to a large
bladder tumour.
CASE 57
57a
History
A 36-year-old male presented with
progressive dysphagia.
103
Answer 57
Abdominal Imaging
ANSWER 57
Observations (57a)
This frontal chest radiograph of an adult patient shows an
added convex soft tissue density along the right mediastinal
border and behind the heart. There is no normal gastric
air bubble beneath the left hemidiaphragm. The findings
suggest dilatation of the oesophagus secondary to chronic
distal obstruction, most likely due to achalasia. A barium
swallow would confirm.
Diagnosis
Achalasia.
Differential diagnosis
Secondary achalasia due to a stricture at the gastrooesophageal junction. There will be normal peristalsis
however.
Chagas disease is essentially the same as achalasia but
the neurenteric plexus damage is due to Trypano so ma
cruzi infection.
Discussion
Practical tips
57b
Further management
The condition is further investigated with pressure
measurements (manometry) and endoscopy.
Treatment is most commonly by pneumatic dilatation
of the gastro-oesophageal sphincter. Surgical
myotomy is considered where there is disease
recurrence.
104
Abdominal Imaging
Case 58
CASE 58
History
An 18-year-old male presented with
headaches.
58a
58b
58c
105
Answer 58
Abdominal Imaging
ANSWER 58
Observations (58a, 58b, 58c)
Three images from an IVU series are provided but no
control film (which would normally be assessed prior to
interpretation of the post-contrast films). Images show
unilateral increasingly dense and persistent nephrogram on
the right. The right kidney shows uniform smooth
reduction in size when compared to the left. There is
delayed excretion of contrast by the right kidney on the 10
minute film (58c). These appearances suggest unilateral
right renal artery stenosis. The young age of the patient
makes fibromuscular dysplasia more likely than
atherosclerosis as the underlying pathology.
Diagnosis
Renal artery stenosis.
Differential diagnosis
For persistent dense nephrogram:
Unilateral:
Obstruction acute obstruction is the most
common cause of this sign.
Renal artery stenosis/ischaemia.
Renal vein thrombosis.
Acute bacterial pyelonephritis.
Acute papillary necrosis.
Bilateral:
Hypotension/shock.
Acute tubular necrosis.
Acute glomerulonephritis.
Causes of unilateral change involving both kidneys.
Practical tips
If there is bilateral delayed persistent nephrogram
with absent or decreased excretion, then the patient
needs to be immediately checked to ensure that
contrast anaphylactic shock has not occurred.
Magnetic resonance or CT angiography is the
preferred investigation for this condition in the
modern era.
Further management
Attempted renal artery angiography and angioplasty are
usually advised.
Discussion
There are two main causes of renal artery stenosis:
Atherosclerosis (8090%) usually in the proximal
2 cm of the renal artery; affects older population >50
years; more common in men; bilateral in one-third.
58d
106
Abdominal Imaging
CASE 59
Case 59
59a
History
A 37-year-old female presented with
acute abdominal pain.
59b
107
Answer 59
Abdominal Imaging
ANSWER 59
Observations (59a, 59b)
Single image from a barium follow-through examination
shows smooth thickened small bowel folds. Selected axial
images from an IV contrast enhanced CT scan of the
abdomen again demonstrates smooth thickening of bowel
folds in dilated loops of fluid-filled small bowel. In addition,
there is thrombus seen in the mid superior mesenteric vein.
Diagnosis
Small bowel ischaemia secondary to superior mesenteric
vein (SMV) thrombosis.
Differential diagnosis
For smooth thickened folds:
Haemorrhage.
Ischaemia:
Acute embolus, HenochSchnlein purpura
(HSP).
Chronic vasculitis, thromboangiitis obliterans,
radiotherapy.
Oedema:
Hypoproteinaemia cirrhosis, nephrotic syndrome,
protein-losing enteropathy.
Angioneurotic oedema.
Lymphatic obstruction lymphoma, mesenteric
fibrosis, intestinal lymphangiectasia.
Discussion
Small bowel/mesenteric ischaemia can present very acutely
with symptoms of acute abdominal pain, vomiting,
diarrhoea and rectal bleeding. This is usually due to arterial
thrombus, dissection or acute venous obstruction. Chronic
ischaemia usually due to chronic arterial thrombus has a
Practical tips
Look carefully for linear gas shadows within the
bowel wall indicative of intramural gas.
Portal vein gas is usually seen in the periphery of the
liver as well as centrally, in contrast to biliary gas,
which is usually only central. This is a premorbid sign
in adults.
Further management
Investigation with CT can both diagnose and identify the
complications of ischaemia.
59c
108
Abdominal Imaging
CASE 60
Cases 60, 61
60
History
A 23-year-old male presented with a
history of renal tract calculi.
CASE 61
61
History
A 57-year-old male presented with
lower abdominal pain.
109
Answers 60, 61
Abdominal Imaging
ANSWER 60
Observations (60)
Discussion
Diagnosis
Neurogenic bladder.
Differential diagnosis
For small bladder:
Infection schistosomiasis/TB.
Iatrogenic postsurgery/radiotherapy.
Neurogenic.
Transitional cell carcinoma (TCC) asymmetric
bladder contraction with thick wall and filling defects.
Extrinsic compression usually gives a pear shaped
bladder appearance.
Practical tips
Inspect IVU films carefully to look for a spinal
abnormality, which can help to determine the underlying
cause of the bladder abnormality.
Further management
In the absence of an easily identifiable cause, lumbosacral
spine MRI can be useful.
ANSWER 61
Observations (61)
Colonic metastases.
Discussion
Practical tips
Diagnosis
110
Further management
Clinical review of patient to try and localize a likely primary
tumour. CT scanning will confirm peritoneal disease and
may well reveal the primary tumour.
Further reading
Sheth S, Horton KM, Garland MR, Fishman EK (2003).
Mesenteric neoplasms: CT appearances of primary
and secondary tumors and differential diagnosis.
Radio Graphics 23: 457473.
Abdominal Imaging
CASE 62
Cases 62, 63
62a
History
A 46-year-old female, recently
emigrated to the UK from Africa,
presented with symptoms of urinary
frequency and urgency.
CASE 63
63
History
A 45-year-old diabetic presented with
pyrexia and abdominal pain.
111
Answer 62
Abdominal Imaging
ANSWER 62
Observations (62a)
Practical tips
Further management
Diagnosis
Schistosomiasis.
Differential diagnosis
For calcified bladder wall:
Cancer primarily transitional cell carcinoma (TCC)
but also other rarer bladder tumours.
Radiotherapy.
Infection TB and schistosomiasis.
62b
Discussion
Schistosomiasis is one of the most common parasitic
infections, affecting 8% of the global population.
Schisto so ma haemato b ium is the female parasite which
affects the genitourinary system. Unlike TB, which tends
to affect the kidneys first and then spreads caudally,
schistosomiasis has a reverse involvement and usually is
confined to bladder and lower ureters. (Another case of
bladder schistosomiasis [62b] is shown note the absence
of upper tract calcification that one might see in TB.)
Classically, the patient presents with urinary frequency,
urgency and dysuria. Imaging findings are of:
Calcification of the bladder which results in reduced
bladder filling capacity and increased postmicturition
residual volume.
Calcification of the lower ureters.
Lower ureteric strictures.
Ureteritis cystica.
Complications of disease affecting the genitourinary system
include:
Cystitis.
Vesicoureteric reflux and subsequent pyelonephritis.
Increased risk of squamous cell carcinoma of the
bladder.
Other systems can be affected:
Liver oval migration results in portal hypertension
and subsequent oesophageal varices.
Respiratory system diffuse granulomatous lung
lesions.
112
Answer 63
Abdominal Imaging
Case 64
ANSWER 63
Observations (63)
Supine abdominal radiograph demonstrates gas within the
left pelvicalyceal system and upper ureter. No intraparenchymal renal gas is seen. No gas is seen in the right
renal tract or in the bladder.
Diagnosis
Emphysematous pyelitis.
Differential diagnosis
Of cause of gas in the urinary tract:
Emphysematous pyelonephritis/pyelitis/cystitis.
Gas forming perinephric abscess.
Trauma.
Iatrogenic urinary diversion procedures.
Urinary tract fistula to bowel due to inflammation,
e.g. Crohns, diverticulitis or spreading malignancy.
Discussion
Emphysematous pyelitis is a condition in which infective
organisms produce gas, which is confined within the renal
pelvicalyceal system. In emphysematous pyelonephritis, gas
also forms within the renal parenchyma a life-threatening
condition that requires prompt diagnosis and treatment.
CASE 64
Practical tips
CT is the best imaging modality for assessing extent and
location of gas.
Further management
Depends on cause but obviously infective causes require
prompt, appropriate antibiotic treatment.
Further reading
Joseph RC, Amendola MA, Artze ME, et al. (1996).
Genitourinary tract gas: imaging evaluation.
Radio Graphics 16: 295308.
64a
History
A 39-year-old female presented with
early satiety and epigastric pain.
113
Answer 64
Abdominal Imaging
ANSWER 64
Observations (64a)
Single image from a double contrast barium meal
examination shows a well defined smooth walled ovoid
mass lesion in the gastric antrum. A central smooth ulcer
is present and no calcification is seen.
Diagnosis
Leiomyoma of the stomach.
Differential diagnosis
For target lesions:
Neurofibroma.
Lipoma (64b).
Ectopic pancreatic rest.
Metastases commonly breast, lung, renal and
malignant melanoma.
Haemangioma.
Practical tips
Smooth, well defined, slow growing gastric lesions are
likely to be benign.
Discussion
Further management
64b
114
Abdominal Imaging
CASE 65
Cases 65, 66
65a
History
A 45-year-old female presented with per
rectal bleeding.
CASE 66
66a
History
A 42-year-old smoker with a family history
of bowel cancer.
(see page 118 fo r case answer)
115
Answer 65
Abdominal Imaging
ANSWER 65
Observations (65a)
Single image from a double contrast barium enema
examination shows abnormality of the colon that extends
from the rectum to the mid transverse colon. There are
features of luminal narrowing with mucosal irregularity,
granularity and shallow ulceration. The disease process
appears continuous along the affected segments with no
further lesions seen. Normal appearances of the ileocaecal
region. Normal sacroiliac joints. The appearances are in
keeping with a colitis, most likely ulcerative colitis.
Diagnosis
Ulcerative colitis (UC).
Discussion
Ulcerative colitis is an idiopathic inflammatory bowel
disease with involvement predominantly of the mucosa and
submucosa of the large bowel. There are two peaks of
presentation 3rd5th decades and 7th8th decades. The
most common presentation is with bloody diarrhoea and
abdominal pain.
The rectum is almost always involved (96% of cases)
with continuous, concentric and symmetric involvement of
the colon more proximally. The terminal ileum is involved
in 1025% due to backwash ileitis. In acute inflammation
there are findings of:
65c
65b
116
Answer 65
Abdominal Imaging
Practical tips
Further management
65d
65e
117
Answer 66
Abdominal Imaging
ANSWER 66
Observations (66a)
Single image from a double contrast barium examination
is shown. There are multiple submucosal lesions seen
scattered throughout the colon with no regional
predominance. Close inspection shows that these are due
to gas-filled cysts in the bowel wall. No free intraabdominal gas is seen to suggest perforation. No linear gas
collections are seen. No portal vein gas is seen.
Diagnosis
Practical tips
Discussion
Pneumatosis cystoides intestinalis is usually a benign
condition of middle aged people who tend to be
asymptomatic but can present with symptoms of vague
abdominal pain, diarrhoea and mucous discharge.
Radiological findings are of multiple small 15 mm gasfilled cysts in a subserosal/submucosal distribution. They
are more commonly found on the mesenteric rather than
antimesenteric side of the colon. The cysts can rupture
66b
118
Further management
Pneumatosis of the colon is usually not clinically significant
the importance here is to treat the patient, not the x-ray.
Further reading
Pear BL (1998). Pneumatosis intestinalis: a review.
Radio lo gy 207: 1319.
Abdominal Imaging
Cases 67, 68
CASE 67
History
A 56-year-old male with lung cancer.
67
CASE 68
68
History
A 46-year-old male presented
recurrent urinary tract infections.
with
119
Answers 67, 68
Abdominal Imaging
ANSWER 67
Observations (67)
Selected in and out of phase T1 weighted axial images of
the abdomen are provided, the out of phase image lying to
the right. There is enlargement of the left adrenal gland
which appears of intermediate signal intensity on T1 in
phase and shows signal drop out on the T1 out of phase
image. Appearances on this chemical shift MRI are
consistent with fatty content and indicative of a benign
adenoma.
Diagnosis
Adrenal adenoma.
Discussion
Adrenal lesions are found in ~9% of the general population.
Adrenal adenomas are the most common adrenal lesion.
Imaging features can be used to differentiate benign
adenomas from primary malignant (carcinoma, phaeochromocytoma) or metastatic adrenal lesions.
Imaging features for differentiation of an adenoma from
metastasis are:
Adenomas are mostly <2.5 cm in size; lesions >4 cm in
size are more likely to be metastases or adrenal
carcinomas.
Lesions showing no growth over 6 months are usually
benign.
On unenhanced CT adenomas often contain
intracellular fat, lowering the overall density on CT.
When <10 Hounsfield units (HU), this is highly
specific for adenoma (96% specificity). Some
adenomas contain less fat and so a lesion with HU
>10 may represent adenoma or malignant lesion.
On IV contrast enhanced CT both adenomas and
metastases enhance, but adenomas washout more
rapidly. After a plain scan, acquire postcontrast scans
at 60 s (early) and 10 min (delayed).
% washout =
early-delayed
( early-unenhanced
) x 100
Practical tips
An incidental enlarged adrenal picked up on US/CT/MRI
should be further investigated with a chest radiograph to
look for a lung neoplasm.
Further management
Adrenal adenoma should be followed up after 6 months.
Lesions that grow by over 1 cm in this time or those that
measure over 4 cm should be considered for surgery.
Hormonally active lesions may also be considered for
surgery.
Further reading
Mayo-Smith WW, Boland GW, Noto RB, Lee MJ
(2001). State-of-the-art adrenal imaging.
Radio Graphics 21: 9951012.
ANSWER 68
Observations (68)
Discussion
Practical tips
Diagnosis
120
It is associated with:
Renal calculi.
Infection.
Reflux.
Megaureter.
Cryptorchidism.
Urethral valves.
Multicystic dysplasia.
Further management
No active management is required.
Abdominal Imaging
CASE 69
Cases 69, 70
69
History
A 25-year-old female presented with
fatigue and steatorrhoea for 12 months.
CASE 70
70
History
A 26-year-old male was involved in a
road traffic accident.
121
Answers 69, 70
Abdominal Imaging
ANSWER 69
Observations (69)
Single image from a small bowel enema examination is
shown. The tip of the small bowel enema catheter is seen
in the proximal duodenum. The examination demonstrates
a reversal of fold pattern with an increased number of folds
seen in the ileum and a reduction in the number of small
bowel folds seen in the proximal jejunum. These features
suggest malabsorption in the proximal small bowel such as
coeliac disease.
Diagnosis
Coeliac disease.
Discussion
Coeliac disease is a gluten-sensitive enteropathy
characterized histologically by villous atrophy. The
duodenum and jejunum are affected more than the ileum
because some proximal gluten digestion means that less
reaches the distal small bowel. It classically presents with
steatorrhoea and diarrhoea, but more commonly presents
in less specific ways such as fatigue, weight loss and
abdominal pain. Malabsorption can also result in anaemia,
osteomalacia, neuropathy and oedema. Age at presentation
can vary from early childhood to late middle age.
Imaging features of coeliac disease include:
Small bowel dilatation (due to reduced motility) is the
most common imaging finding.
Reduced number of folds in the jejunum.
Jejunalization of the ileum an increased number of
ileal folds. This is a response to the reduced mucosal
area in the jejunum.
Practical tips
Folds in the jejunum are normally thicker and more
numerous than the ileum. Expect to see seven folds
per inch in the jejunum and three to four folds per
inch in the ileum. A reversal of this pattern should
raise suspicion of coeliac disease.
If the radiological features deteriorate while on a
gluten-free diet, raise the possibility of complications
such as lymphoma.
Further management
Confirmation of diagnosis is made with endoscopic small
bowel biopsy.
ANSWER 70
Observations (70)
Practical tips
Further management
Diagnosis
Pear shaped urinary bladder secondary to pelvic
haematoma.
Differential diagnosis
For pear shaped bladder (mnemonic HELP):
Haematoma.
External iliac artery aneurysms.
Lymphadenopathy.
Pelvic lipomatosis.
122
Abdominal Imaging
Case 71
CASE 71
History
A 58-year-old female with an incidental
liver lesion detected on ultrasound.
71a
71b
71c
123
Answer 71
Abdominal Imaging
ANSWER 71
Observations (71a, 71b, 71c)
Discussion
Diagnosis
Cavernous haemangioma.
Differential diagnosis
For hyperechoic hepatic lesions on US:
Haemangioma.
Focal nodular hyperplasia (FNH).
Adenoma.
Metastasis.
Hepatocellular carcinoma.
Lipoma.
71d
124
71e
Answer 71
Abdominal Imaging
Case 72
Practical tips
Further management
Further reading
Vilanova JC, Barcel J, Smirniotopoulos JG, et al.
(2004). Hemangioma from head to toe: MR imaging
with pathologic correlation. Radio Graphics 24:
367385.
CASE 72
History
A 43-year-old male presented with
central abdominal pain.
72a
72b
72c
72d
125
Answer 72
Abdominal Imaging
ANSWER 72
Observations (72a, 72b, 72c, 72d)
Several axial CT images of the abdomen with IV contrast
enhancement in the portal venous phase are shown. There
is significant stranding of the peripancreatic fat indicative
of acute inflammation, which is predominantly around the
pancreatic tail. Within the pancreatic tail, there is a
moderate sized fluid-filled cystic lesion, which would be
consistent with a pancreatic pseudocyst in a patient with
pancreatitis. The local inflammatory change appears to
extend to involve the distal transverse colon at the splenic
flexure. In addition, there is central low attenuation within
the portal vein extending into the proximal splenic vein in
keeping with portal/splenic vein thrombosis. The
pancreatic duct is dilated at 4 mm diameter. While the
whole gallbladder has not been imaged no gallstones are
seen on these images. The visualized liver edge is smooth
and liver has normal attenuation.
Diagnosis
Pancreatitis.
Practical tips
Look for the two main causes of pancreatitis alcohol
and gallstones. US is required to look for gallstones
and can be used to look for complications, e.g.
pseudocyst formation and portal vein thrombosis.
Look for the main complications of pancreatitis.
Assessing the pancreas is best done by three phase CT
imaging with a pre-contrast and pancreatic phase
(~40 s) scan of the pancreas, followed by portal
venous phase scans of the abdomen and pelvis. The
pre-contrast scan will allow for assessment of
calcification in the pancreas to determine whether this
is an acute-on-chronic episode. Pancreatic phase scans
best assess for areas of necrosis and focal mass lesions.
Portal venous imaging allows for assessment of local
disease and complications.
Discussion
Pancreatitis is an acute inflammatory condition. There are
two main types of pancreatitis oedematous and necrotic.
Oedematous pancreatitis is the much more common form,
characterized by gland oedema, whereas necrotic pancreatitis is rarer and is complicated by pancreatic haemorrhage
and necrosis.
Appearances of the pancreas in pancreatitis can therefore
be variable, with the pancreas appearing normal, having
areas of nonenhancement due to necrosis, having areas of
increased attenuation due to haemorrhage, or appearing
enlarged and oedematous. Universally, streaking into the
surrounding fat due to inflammation is observed.
Causes of pancreatitis include:
Alcoholism and gallstones are the two most common
causes of acute pancreatitis. Assess for signs of alcohol
excess by looking for fatty change in the liver (diffuse
low attenuation on CT, raised echogenicity on US),
cirrhosis (irregular nodular surface to the liver which is
atrophic) and portal hypertension (splenomegaly and
varices). Assess for gallstones with US initially, then
MRCP if there is still uncertainty.
Infections hepatitis, mumps.
Trauma.
Hypercalcaemia from multiple myeloma, sarcoidosis,
amyloidosis.
Drugs, e.g. steroids, diuretics (frusemide, thiazides),
azathioprine.
Malignancy.
Pancreatitis can be complicated by pseudocyst formation;
abscess formation (usually develops 2 weeks after acute
inflammation onset); spread of local inflammation to
involve bowel loops resulting in strictures, colitis and
perforation; portal vein, splenic vein, SMV thrombosis;
ascites and chest complications pleural effusion (usually
left sided), empyema, unilateral pulmonary oedema.
126
Further management
Treatment is usually conservative although necrotizing
pancreatitis may well need more aggressive management
involving surgery or percutaneous radiologically guided
drainage.
72e
Abdominal Imaging
CASE 73
Cases 73, 74
73
History
A 34-year-old male presented with
scrotal tenderness.
CASE 74
74
History
A 56-year-old male presented with
haematuria and chronic renal failure.
127
Answers 73, 74
Abdominal Imaging
ANSWER 73
Observations (73)
Ultrasound longitudinal image of the right testicle
demonstrates multiple small hyperechoic foci, with no
posterior acoustic shadowing, distributed evenly
throughout the testicle. The testicle is otherwise of normal
size and shape. No other focal mass lesion is identified.
Associations include:
Cryptorchidism.
Infertility.
Klinefelters.
Downs syndrome.
Male pseudohermaphrodism.
Alveolar microlithiasis.
Diagnosis
Testicular microlithiasis.
Discussion
Testicular microlithiasis is a condition characterized by
failure of clearance of degenerated tubular epithelium from
the seminiferous tubules, which subsequently calcify. This
is an asymptomatic condition and is an uncommon
incidental finding. Image findings on US are of multiple
small 12 mm hyperechoic foci with no acoustic shadowing, distributed throughout both testes. Atypical
appearances of asymmetrical and unilateral foci are also
seen. There is an increased risk of testicular germ cell
tumour in 40% and therefore follow-up with 6 monthly US
is often advised.
Practical tips
Identifying the distribution of calcific foci is important,
since a cluster of calcification within a hypoechoic area
suggests tumour or chronic testicular infarction. Infarction
can be due to torsion, trauma or severe epididymitis.
Further management
Urological referral with follow-up testicular US at 6
monthly intervals to screen for malignancy.
ANSWER 74
Observations (74)
Single AP abdominal radiograph demonstrates amorphous,
putty-like calcification within a shrunken right kidney.
Diagnosis
Renal tuberculosis with autonephrectomy.
Discussion
The urogenital tract is the second most common site to be
affected by TB, after the lungs. Renal TB is found in 510%
of patients with pulmonary TB, but there is only
radiographic evidence of pulmonary TB in fewer than 50%.
The kidney is usually affected first, via haematogenous
spread from a lung/bone/GI focus. There can then be
contiguous spread of infection to involve the ureters and
bladder. Renal TB is unilateral in 75% of cases and the most
common appearance is of a small, shrunken, scarred,
nonfunctioning kidney.
Less common appearances are of:
Cortical scarring.
Renal pelvis/infundibular strictures resulting in
hydrocalycosis and amputated calyx.
Nephrolithiasis.
Dystrophic parenchymal calcification.
128
Practical tips
Urinary tract TB spreads in an antegrade fashion.
Check chest radiograph for signs of pulmonary TB
but this is only seen in about 50% of cases.
Further management
Medical drug therapy for TB should be initiated.
Abdominal Imaging
CASE 75
Cases 75, 76
75
History
A 57-year-old male patient presented
with abdominal pain.
CASE 76
76
History
A 58-year-old female presented with
early satiety.
129
Answers 75, 76
Abdominal Imaging
ANSWER 75
Observations (75)
Supine abdominal radiograph shows a positive Rigler sign
suggestive of pneumoperitoneum. There is also outlining
of the falciform ligament and the left lateral umbilical
ligament with a large area of free gas seen overlying the
liver. These findings are consistent with pneumoperitoneum.
Diagnosis
Pneumoperitoneum.
Differential diagnosis
Of causes of pneumoperitoneum:
Trauma.
Iatrogenic causes, e.g. laparotomy usually gas should
have resolved within 3 days and its presence is
suspicious after this; although it can take up to 3
weeks to resolve in some cases. Faster absorption
occurs with CO2 and in obese patients.
Perforation of abdominal viscus.
Ruptured pneumatosis intestinalis.
Rupture of an abscess.
Extension from chest, i.e. pneumomediastinum,
bronchopleural fistula.
Through female genital tract, e.g. intercourse,
waterskiing.
Discussion
There are a variety of signs that aid in the detection of free
intraperitoneal gas.
Practical tips
If there is any doubt about the diagnosis then an erect
chest radiograph or a left lateral decubitus film of the
abdomen should be acquired.
Further management
Free intraperitoneal gas is suggestive of a perforated viscus
and is a surgical emergency inform the surgical team
immediately.
Further reading
Levine MS, Scheiner JD, Rubesin SE, et al. (1991).
Diagnosis of pneumoperitoneum on supine
abdominal radiographs. American Jo urnal o f
Radio lo gy 156: 731735.
ANSWER 76
Observations (76)
Discussion
Diagnosis
Linitis plastica due to gastric carcinoma.
Practical tips
Differential diagnosis
130
Further management
Referral to a gastroenterologist for endoscopy +/ biopsy
is appropriate.
Further reading
Ba-Ssalamah A, Prokop M, Uffmann M, et al. (2003).
Dedicated multidetector CT of the stomach:
spectrum of diseases. Radio Graphics 23: 625644.
Abdominal Imaging
Case 77
CASE 77
History
A 50-year-old female presented with
recurrent urinary tract infection.
77a
77b
131
Answer 77
Abdominal Imaging
ANSWER 77
Observations (77a, 77b)
Discussion
Diagnosis
Pyeloureteritis cystica.
Differential diagnosis
For radiolucent filling defects in the ureters:
Radiolucent calculi.
Transitional cell carcinoma (TCC).
Pyeloureteritis cystica.
Blood clots.
Ureteric polyps.
Sloughed renal papillae.
Practical tips
Although any part of the ureter may be involved, there is
slight predilection for the upper third.
Further management
Characteristic IVU appearances may well permit a
confident diagnosis. However, if there is diagnostic
uncertainty then ureteroscopy with biopsy may sometimes
be required. Antibiotic treatment may be undertaken,
though the response is variable.
77b
132
Abdominal Imaging
CASE 78
Case 78
78a
History
A 52-year-old female with diabetes
presented with renal failure.
78b
133
Answer 78
Abdominal Imaging
ANSWER 78
Observations (78a, 78b)
Two images from an IVU series are shown. There is
evidence of renal papillary swelling and enlargement. The
interpolar calyces on the right have a ball on tee
appearance with a collection of contrast material in the
centre of the papilla. A partial duplex system is also
demonstrated on the right. There is a well defined
intraluminal non-opaque filling defect in the upper ureter
on the right, which represents a sloughed papilla.
Diagnosis
Practical tips
Differential diagnosis
Of causes of renal papillary necrosis (mnemonic SAD
ROPE):
Sickle cell disease.
Analgesics.
Diabetes.
Renal vein thrombosis.
Obstructive uropathy.
Pyelonephritis.
Ethanol abuse.
Discussion
Further management
78b
134
Abdominal Imaging
Cases 79, 80
CASE 79
CASE 80
History
History
A 36-year-old immunocompromised
patient presented with dysphagia.
79
80a
80b
135
Answers 79, 80
Abdominal Imaging
ANSWER 79
Observations (79)
Single image from a barium swallow examination shows a
shaggy, ulcerated mucosal pattern in the thoracic
oesophagus typical of candidiasis.
Diagnosis
Candida oesophagitis.
Discussion
Candida oesophagitis is the most common cause of
infectious oesophagitis with C. alb icans being the most
commonly involved organism. Immunocompromised
patients have a predisposition to infection. Presentation is
with gradual dysphagia, odynophagia and retrosternal pain.
Association with oral infection is seen in up to 80%,
characterized by several patchy, white plaques covering the
mucosa. In the oesophagus there is predilection for the
upper half o f the o eso phagus with the appearance of
multiple, shaggy, longitudinal mucosal plaques. There is
reduction in primary peristalsis and some narrowing of the
lumen due to spasm and oedema. Stricture formation is a
rare complication.
Other infective causes of oesophagitis include:
Herpes oesophagitis the second most common cause
of infectious oesophagitis. Caused by herpes simplex
virus (HSV) type 1 and most commonly presenting in
males in 2nd4th decades. Usually involving the mid
oesophagus, there are multiple small discrete
superficial punctate ulcers. The intervening mucosa is
usually of normal appearance.
Practical tips
Do not mistake pseudodiverticulosis of the oesophagus for
deep ulceration. This is a benign condition where
oesophageal mucous glands become dilated and form flaskshaped outpouchings from the lumen. It is associated with
any severe oesophagitis (see Case 38).
Further management
Always consider immunocompromisation if not
already apparent.
Oropharyngeal candidiasis may be a pointer to the
nature of oesophageal ulceration but upper GI
endoscopy is still often needed to confirm via biopsies
and brushings.
Antifungal or antiviral drugs for treatment as
appropriate.
ANSWER 80
Observations (80a, 80b)
Diagnosis
Practical tips
Carolis disease.
Discussion
Carolis disease is a rare autosomal recessive disorder
characterized by multifocal, cystic dilatation of the
intrahepatic bile ducts. The differential diagnosis for this
condition is polycystic liver disease, however the two can
be discriminated by identifying the communication
between cysts and bile ducts in Carolis.
136
Further management
If there is any concern as to whether the cysts are
communicating, MRCP (magnetic resonance cholangiopancreatography) is a noninvasive method of clarification.
Abdominal Imaging
Cases 81, 82
CASE 81
History
A 42-year-old female presented with
pelvic pain and menorrhagia.
81a
CASE 82
81b
82a
History
A 47-year-old presented with right
upper quadrant abdominal pain.
137
Answers 81, 82
Abdominal Imaging
ANSWER 81
Observation (81a, 81b)
Two MRI images are presented T2 weighted sagittal and
axial images through the pelvis. These images show bulky
enlargement of the uterus. The junctional zone is widened
and poorly defined and there are multiple high signal foci
within the myometrium in keeping with ectopic
endometrial tissue. These appearances are typical of
adenomyosis.
Diagnosis
Adenomyosis.
Discussion
Adenomyosis is a chronic condition affecting women
during the reproductive years. There is an increased
incidence in multiparous women, suggesting that uterine
trauma plays a role in the development of this disease. The
disease is characterized by ectopic endometrial tissue
spreading into the myometrium resulting in myometrial
hyperplasia. The condition is benign and although it is
associated with endometriosis, there is no increased risk of
developing endometrial/uterine malignancies. The disease
can be either focal or diffuse. It can sometimes be difficult
Practical tips
Widening of the junctional zone with ectopic endometrial
cysts are the best MRI features for diagnosis.
Further management
Hysterectomy is the only management option to relieve
symptoms.
ANSWER 82
Observations (82a)
Single AP radiograph of the abdomen demonstrates a large
mass lesion in the right upper quadrant, which shows
curvilinear calcification of the wall. Appearances would best
fit with this being a calcified wall of the gallbladder. No
discontinuous areas in calcification are seen.
Diagnosis
Porcelain gallbladder.
Differential diagnosis
Similar appearances on US can be due to:
Emphysematous cholecystitis.
Gallbladder filled with stones.
Normal gas-filled bowel.
Discussion
This is an idiopathic condition that was coined to describe
the blue discolouration and brittle nature of the gallbladder
at surgery. The condition is associated with gallstones in
90% of cases and is more frequently seen in women (sex
ratio of 5:1). Patients are usually asymptomatic and
diagnosis is made incidentally on plain films or US
imaging. Radiographic appearances mirror the histological
findings of dystrophic calcification in a chronically inflamed
gallbladder. The calcification can be of two types:
Curvilinear calcification in the muscularis (82b).
Punctate calcification in the mucosa/glandular spaces.
138
Practical tips
Ultrasound and CT scans should be scrutinized for
secondary gallbladder malignancy when porcelain
gallbladder is noted.
A discontinuity in the calcification when the whole
gallbladder wall appears to be calcified may be a clue
to gallbladder carcinoma.
Further management
Cholecystectomy is advised due to the high risk of tumour.
Further reading
Kane R, Jacobs R, Katz J, Costello P (1984). Porcelain
gallbladder: ultrasound and CT appearances.
Radio lo gy 152: 137141.
Answer 82
Abdominal Imaging
Case 83
82b
CASE 83
History
A 38-year-old female presented with
severe dysmenorrhoea and menorrhagia.
83a
83b
83c
139
Answer 83
Abdominal Imaging
ANSWER 83
Observations (83a, 83b, 83c)
Three MRI images are shown a sagittal T2 weighted
image (83a), axial T1 (83b) and axial T1 weighted fat
suppressed image (83c). There is a large 4 cm lesion
identified within the left ovary, which is of high signal on
both T1 and T2 weighted images and shows no fat
suppression. On the sagittal T2 weighted image, there is
evidence of layering of the contents of this mass. These
appearances would be entirely consistent with blood
products and the lesion represents an endometrioma.
Diagnosis
Endometrioma.
Discussion
Endometriosis is a chronic condition characterized by
ectopic deposits of endometrium outside the uterine cavity.
It affects women in the 4th6th decades and is
characterized by chronic pelvic pain, dysmenorrhoea,
menorrhagia and dyspareunia. Common sites for
endometrial deposits are the ovaries, fallopian tubes, pouch
of Douglas and uterosacral ligaments, however more distal
spread can occur to the bladder/bowel wall with even
further distal spread to the lungs and pleura. Spread to the
GI tract most commonly occurs to the distal sigmoid and
the rectosigmoid wall and deposits can result in peritoneal
adhesion and subsequent obstruction. Repeated bleeding
of the ectopic endometrial deposits results in fibrosis and
pain.
Practical tips
Endometriomas can be differentiated from dermoid cysts
by using a fat suppressed MRI sequence. Both will show
high signal on T1 and T2 weighted images but
endometriomas will still be high signal on fat suppressed
sequences.
Further management
This condition can be difficult to control. Medical
management with hormonal suppression of menstruation
is often attempted but surgical excision may be required.
83c
140
Abdominal Imaging
Case 84
CASE 84
History
A 34-year-old female presented
with vague abdominal pain.
84a
141
Answer 84
Abdominal Imaging
ANSWER 84
Observations (84a)
This single image from a double contrast barium enema
shows abnormality of the sigmoid colon with poor
distension and apparent external compression of the bowel
loops inferiorly. Three well defined calcific densities are seen
adjacent to the affected segment and have the appearance of
teeth.
Diagnosis
Ovarian dermoid.
Discussion
Ovarian dermoid cysts are benign lesions, which are
relatively common, accounting for ~20% of all ovarian
neoplasms. These mostly present during the reproductive
years, with a mean age of presentation of 30 years. They
contain tissue from all three germ cell layers ectodermal
(skin, brain), mesodermal (muscle, fat) and endodermal
(mucinous/ciliated epithelium). Tumours are bilateral in
~10%.
Typical appearance is of a unilocular cyst, lined by
squamous epithelium and containing sebaceous, fatty
material with hair follicles and skin glands arising from the
wall. A protuberance into the cavity known as a Rokitansky
nodule is usually the site of bone/teeth material.
84b
142
Practical tips
Some films used in radiological exams rely on the candidate
noting an incidental lesion at the edge of the film. Teeth
in ovarian dermoids are a classical example of an edge of
the film case!
84c
Answer 84
Abdominal Imaging
Further management
Further reading
84d
84f
84e
143
Abdominal Imaging
CASE 85
History
Incidental liver lesion was noted on
abdominal ultrasound scan of a 26-yearold female.
85a
144
T2 weighted
T1 weighted in phase
Case 85
Abdominal Imaging
Case 85
85b
145
Answer 85
Abdominal Imaging
ANSWER 85
Observations (85a, 85b)
Selected pre- and post-contrast MRI images of the liver.
Pre-contrast images (85a) demonstrate a large, well defined
lesion in segment 4 of the liver, which is of slightly reduced
signal on T1 weighted images. Out of phase T1 weighted
images show no significant alteration of liver signal to
suggest the area is due to focal fatty sparing. The lesion is
slightly hyperintense on T2 weighted scans.
On dynamic post-contrast imaging (85b), the lesion
shows marked enhancement during early arterial (25 s)
phase with a central hypointense scar visible at this stage.
There is subsequent wash out of contrast in the portal (60
s) and equilibrium (3 min) phases to become isointense
with liver. The central scar shows enhancement in the
equilibrium phase.
The contrast agent used is gadolinium BOPTA (GdBOPTA) and the image taken at 90 min shows persisting
contrast uptake within the lesion indicative of hepatocyte
content. These appearances and pattern of enhancement
would best fit with the diagnosis of focal nodular
hyperplasia.
Diagnosis
Focal nodular hyperplasia (FNH).
Differential diagnosis
For hepatic lesion with central scar:
FNH.
Adenoma.
Hepatocellular carcinoma.
Haemangioma.
Fibrolamellar carcinoma.
Discussion
Focal nodular hyperplasia is a benign hepatic lesion that
occurs most commonly in young/middle aged women.
Usually these patients are asymptomatic, with diagnosis
made as an incidental finding, although some patients can
present with vague abdominal pain. They are solitary
(8595%) vascular lesions containing normal hepatic
elements Kupffer cells, hepatocytes and bile ducts.
Imaging features are very similar to those of hepatic
adenomas. Unlike hepatic adenomas, development is not
associated with the oral contraceptive pill, though
oestrogens can exert trophic effects.
Focal nodular hyperplasia is divided into typical and
atypical groups, with approximately 50% in each. Typical
lesions show the signal characteristics, enhancement pattern
and central scar as described below. Atypical lesions may
show signal heterogeneity, with more marked T1 and T2
hyperintensity, and no central scar.
Imaging features on CT and MRI: classical FNH is
isodense on CT, while MRI shows mild T1
hypointensity and mild T2 hyperintensity. There is
prominent enhancement in the arterial phase
following IV contrast, the central scar being
conspicuous at this point due to nonenhancement.
Contrast washes out rapidly in the portal and
equilibrium phases to become similar to normal liver,
though there may be scar enhancement in the
equilibrium phase.
146
Practical tips
Sulphur colloid scans have traditionally been used to
help confirm FNH suspected on CT and MRI by
virtue of the presence of Kupffer cells. Liver specific
contrast agents as described above may now obviate
this in many cases.
Hepatic adenoma is a common differential when
FNH is considered and there is evidence that agents
such as Gd-BOPTA can help differentiate FNH from
hepatic adenoma by demonstrating the presence of
functioning liver tissue in the former.
Further management
Differentiation from adenoma and hepatocellular
carcinoma can sometimes be difficult even with histological
information. Excision is then carried out.
Further reading
Schneider G, Grazioli L, Saini S (2005). MRI o f the
Liver. Springer, New York.
Chapter 3
CENTRAL NERVOUS
SYSTEM, HEAD AND
NECK IMAGING
CT AND MRI HEAD
As for all imaging, if an abnormality is not obvious at first
sight, check all areas systematically:
Establish if IV contrast has been given.
Ventricles check the configuration and size, ensuring
the size is appropriate for the other extra-axial CSF
spaces such as the sulci.
Cerebral hemispheres, brainstem and cerebellum on
MRI in particular, there is a lot of information to
evaluate for focal masses, signal abnormalities and
structural abnormalities! In examination vivas, it may
be unrealistic to expect the candidate to quickly detect
subtle abnormalities so you may well be given some
assistance or just presented with selected images. A
rapid evaluation of FLAIR (fluid attenuated inversion
recovery) or PD (proton density) sequences may
quickly lead you to pathology on MRI.
Extra-axial spaces carefully check for normal size,
absence of blood or other collections.
Vessels check for enhancement on CT and normal
flow voids on MRI (including vessels at the skull
base).
The periphery assess orbits, sinuses, temporal
bones/skull base and skull vault.
Everyone has their own blind spots but here are some
suggested areas to check when all else seems normal:
The temporal lobes and posterior fossa on CT
images of the temporal lobes are often degraded by
streak artefact and pathology easily missed. The same
applies to a lesser extent in the posterior fossa.
Skull base and petrous bone pathology can be easily
overlooked, especially on MRI where there is a lot to
assess.
Early signs of stroke the early changes of infarction
can be very subtle. Carefully check for subtle focal
swelling and reduced greywhite matter
differentiation. The latter is best detected by using
very narrow windows on CT.
Venous sinus thrombosis and subdural empyema are
two disorders with significant morbidity and mortality
that can be easily overlooked. When presented with an
apparently normal CT of a patient with a history of
convincing acute intracranial pathology, always double
check for increased density in the venous sinuses and
subtle subdural collections. Administration of IV
contrast may help confirm either.
Haemorrhage subtle subarachnoid or subdural
blood must not be missed. Check carefully for small
147
PLAIN RADIOGRAPHS
Skull
There are a very limited number of pathologies that are
likely to be shown on a skull radiograph:
Trauma
As well as skull fractures, check for indirect signs of fracture
such as fluid levels in sinuses and intracranial air. Remember
to look at all the bones on the film the fracture of
odontoid peg at the edge of the lateral skull film is a basic
exam type of case.
Calcification
Know the normal intracranial calcifications such as pineal
and choroid plexus so that you can differentiate from
pathological calcification such as that associated with
meningioma.
Pituitary
Size and shape of the pituitary fossa should be assessed.
Vault
Several diffuse processes have characteristic changes on the
skull radiograph and make for spot diagnoses, e.g.
acromegaly,
fibrous
dysplasia,
thalassaemia,
hyperparathyroidism and myeloma.
Spine
As always, there are many potential pathologies to see on
plain films of the spine but trauma, infection and neoplasia
are particularly common.
Trauma
When assessing cervical spine films:
First ensure that the complete cervical spine has been
imaged down to C7T1 level.
On the lateral film, look at the anterior spinal,
posterior spinal and spinolaminar lines to ensure
continuity (i.e. imaginary lines drawn along the
anterior and posterior vertebral body cortices and
along the anterior limits of the spinous processes).
148
CASE 86
Cases 86, 87
86a
History
A 13-year-old presented with bilateral
progressive deafness.
CASE 87
87
History
A 10-year-old boy presented with
recurrent painful enlargement of the
parotid gland.
149
Answer 86
ANSWER 86
Observations (86a)
Single high-resolution axial CT image of the skull at the
level of the petrous bone. There is bilateral enlargement of
the vestibular aqueduct. Precise measurements have not
been documented but the aqueducts are clearly significantly
wider than the horizontal semicircular canal seen on the
right.
Diagnosis
Enlarged vestibular aqueduct syndrome.
Discussion
Enlarged vestibular aqueduct syndrome presents clinically
with sensorineural hearing loss. Hearing is usually present
at birth and then deteriorates from age of ~3 years.
Deterioration is often in a stepwise manner, associated with
episodes of minor head trauma. There is a suggestion of an
inherited recessive genetic link and 50% of cases are
bilateral. A degree of cochlear dysplasia is present in 75%
of cases.
The normal endolymphatic duct originates from the
vestibule, via the common crus and extends posterolaterally
in the bony vestibular aqueduct to the endolymphatic sac.
The endolymphatic sac lies on the posterior aspect of the
petrous temporal bone. Enlarged vestibular aqueduct
syndrome is diagnosed when the diameter at its midpoint
Practical tips
A quick assessment of the vestibular aqueducts can be
made by comparing the diameter at midpoint to the
diameter of the adjacent posterior semicircular canal
the aqueduct should not be larger.
When identified, check the cochlea for evidence of
dysplasia.
Further management
Advise on avoiding head trauma where possible, e.g.
no contact sports.
Hearing can be improved with cochlear implants.
Further reading
Dahlen RT, Harnsberger HR, Gray SD et al. (1997).
Overlapping thin-section fast spin-echo MR of the
large vestibular aqueduct syndrome. American Jo urnal
o f Neuro radio lo gy 18: 6775.
Valvassori GE (1983). The large vestibular aqueduct and
associated anomalies of the inner ear. Oto laryngo lo gic
Clinics o f No rth America 16: 95101.
86b
150
Answer 87
Case 88
ANSWER 87
Observations (87)
Single oblique image from a parotid sialogram with no
control film provided for comparison. The parotid duct is
of normal calibre with no obstructing stones or stricture.
There is, however, florid punctate dilatation of the
intraglandular ductules and acini in keeping with punctate
sialectasis.
Practical tips
Diagnosis
Juvenile recurrent parotitis (also known as juvenile punctate
sialectasis).
Discussion
Further management
Further reading
Yam KL, Lau C, Li CK (1997). Primary Sjgren
syndrome presenting as recurrent parotitis. Ho ng
Ko ng Jo urnal o f Paediatrics (New Series) 2: 4750.
CASE 88
History
A 35-year-old male presented with
diplopia.
88a
151
Answer 88
ANSWER 88
Observations (88a)
Coronal T1 weighted MR images of the orbit show marked
bilateral swelling of the muscle bellies of the inferior, medial
and superior rectus muscles with sparing of the tendinous
insertions. This distribution of extraocular muscle swelling
is typical of thyroid ophthalmopathy.
Diagnosis
Thyroid ophthalmopathy.
Differential diagnosis
Orbital pseudotumour usually involves both muscle
belly and tendino us insertio n; is painful compared to
painless thyroid ophthalmopathy and is more commonly
unilateral.
Discussion
Thyroid ophthalmopathy is a disease of the orbit
characterized by deposition of mucopolysaccharides within
the muscle bellies of the intraorbital muscles. It usually
presents in adults and is more common in women. The
patient is usually hyperthyroid (although 10% of cases are
found in euthyroid patients) with ocular presentation
within 1 year of hyperthyroid symptom onset. Severity of
the eye disease, however, is not related to the severity of
the thyroid hormone imbalance.
Radiological features are as follows:
Majority of cases are bilateral although there is often
asymmetrical disease. About 10% are unilateral.
Inferior and medial rectus are most commonly
affected, with the lateral rectus being least likely to be
affected.
Practical tips
The order of muscles involved in thyroid
ophthalmopathy is (from most to least frequent)
Inferior>Medial>Superior>Lateral>Oblique Mnemonic
= IM SLO(w).
Further management
Thyroid ophthalmopathy with visual disturbance requires
prompt evaluation and treatment given the potential risk
to visual function.
Further reading
Hosten N, Sander B, Cordes M, et al. (1989). Graves
ophthalmopathy: MR imaging of the orbits.
Radio lo gy 172: 759762.
88b
88b Selected axial CT images through the orbits show thickening of the medial rectus muscles with sparing of
their tendons.
152
Case 89
CASE 89
History
A 21-year-old male presented with
positional headaches.
89a
89a Axial PD (top left), axial and sagittal T1 weighted (left), axial and coronal T2 weighted
(right) MR images.
153
Answer 89
ANSWER 89
Observations (89a)
Practical tips
Diagnosis
Further management
Colloid cyst.
Differential diagnosis
For 3rd ventricular lesion:
Meningioma these are not usually hyperintense on
T1. Meningiomas commonly calcify and show diffuse
enhancement with contrast.
Arachnoid cyst these are usually isodense on CT and
isointense with CSF on MRI.
Dermoid cyst usually found in the midline. These
contain fat and are therefore usually hypodense on CT
and have mixed signal on MRI.
Ependymoma of the 3rd ventricle these are very
rare. Imaging features include cystic areas, necrosis
and calcification and they show diffuse uniform
enhancement.
Basilar tip aneurysm.
Discussion
Colloid cysts account for approximately 0.51% of CNS
tumours. They usually present in young adults and are
more commonly seen in males. The cysts arise from the
inferior aspect of the septum pellucidum and extend into
the 3rd ventricle. Presentation is usually secondary to
obstructed CSF flow at the level of the 3rd ventricle with
features of positional headache due to transient obstruction,
disturbances of gait, reduced consciousness level and
papilloedema. The majority of cysts (80%) contain
mucinous material while 20% contain fluid similar to CSF.
Typical features on CT: well defined thin walled cyst
in the 3rd ventricle of slightly increased attenuation
with no enhancement (89b). Can cause erosion of the
sella.
Typical features on MRI: mucinous material contained
within the cyst produces a well defined lesion of
increased signal intensity on T1 and T2 weighted
images.
89b
154
CASE 90
Cases 90, 91
90a
History
A 68-year-old male presented with
pyrexia and fits.
CASE 91
91
History
A 54-year-old male presented with
bilateral visual field blurring.
155
Answer 90
ANSWER 90
Observations (90a)
This contrast enhanced CT image of the brain
demonstrates multiple ring enhancing lesions with
surrounding vasogenic oedema in the left frontal lobe.
Though no lesions are seen in the right hemisphere on this
single image, apparent vasogenic oedema in the right
frontal lobe suggests that there may be further lesions on
this side that are not visualized. The differential diagnosis
for ring enhancing lesions is long, but the history of pyrexia
points towards cerebral abscesses being most likely.
Practical tips
Differentiation of the above list can be difficult and
history is very important to identify immune status,
foreign travel and clinical presentation.
Look for complications of abscesses such as rupture
causing meningitis or ventriculitis, radiologically
identified by enhancement of these structures or high
signal in the sulci on FLAIR MR images.
Wall enhancement of cerebral abscess is typically
uniform thick, irregular wall enhancement should
raise suspicion of cerebral metastases.
A peripheral ring on the unenhanced scan is more
common in metastasis than glioma.
Assess paranasal sinuses for a primary source of
infection and ensure a chest radiograph has been done
to look for sources of infection and potential right to
left shunts.
Diagnosis
Cerebral abscesses.
Differential diagnosis
For ring enhancing CNS lesions:
Cerebral abscess.
Metastases.
Toxoplasmosis.
Demyelination.
Lymphoma.
Multicentric glioma.
Multiple infarcts.
Resolving haematomas.
Discussion
Patients who are immunocompromised, on steroids or have
diabetes are more susceptible to CNS abscess formation.
The most common source of infection is haematogenous
spread, though direct spread from infected paranasal sinuses
can also occur. Clinical presentation is with headache,
seizure and pyrexia. Focal infection preceding abscess
formation is cerebritis, and appears as focal low-density
change on CT or high T2 signal on MRI (90b, 90c). This
90b
Further management
MRI with diffusion weighted imaging can sometimes help
differentiate tumour/metastases from abscess. Restricted
diffusion of pus in an abscess cavity means that an abscess
is high signal on DWI and low signal on ADC (apparent
diffusion coefficient) mapping. Opposite findings are seen
with necrotic tumours.
90c
90b, 90c Axial T1 weighted postcontrast and coronal T2 weighted MRI images
of left temporal lobe abscesses. The axial T1 postcontrast image shows an
enhancing rim with surrounding low signal oedema. The coronal image shows
a high signal abscess with significant high signal surrounding oedema causing
a moderate degree of mass effect and midline shift.
156
Answer 91
Case 92
ANSWER 91
Observations (91)
Discussion
Diagnosis
Optic drusen.
Differential diagnosis
For ocular calcification:
Neoplasic causes:
Retinoblastoma (most common cause, accounting
for >50% of cases).
Astrocytic hamartoma.
Choroidal osteoma.
Infection:
Toxoplasmosis.
Rubella.
Cytomegalovirus (CMV).
Herpes simplex.
Other:
Optic drusen.
Phthisis bulbi.
Retinal detachment.
Retinopathy of prematurity.
Hypercalcaemic states hyperparathyroidism,
sarcoidosis, chronic renal failure.
CASE 92
Practical tips
Bilateral calcification does not necessarily suggest a
benign disease process. The nonheritable form of
retinoblastoma (66%) presents at ~24 months with
usually unilateral disease; but the heritable form (33%)
presents at ~12 months with often (66%) bilateral
disease.
Further management
Ophthalmological assessment is required to confirm the
diagnosis and check visual fields and acuity.
92
History
A young adult male presented with
headaches and paralysis of upward gaze.
157
Answer 92
ANSWER 92
Observations (92)
This midline sagittal T1 post-contrast MR image
demonstrates a large, slightly lobulated but well defined
mass in the pineal region. The mass enhances homogeneously, compresses the superior colliculus and causes
dilatation of the 3rd ventricle. The most likely diagnosis is
a pineal germinoma causing Parinauds syndrome and
obstructive hydrocephalus.
Diagnosis
Pineal germinoma.
Differential diagnosis
Of pineal region masses:
Germ cell tumours (>50%):
Germinoma.
Teratoma extremely heterogeneous mass. Occurs
in young children.
Choriocarcinoma.
Embryonal cell tumour.
Pineal parenchymal tumours (25%):
Pineocytoma well demarcated, calcified, slow
growing tumour in middle aged adults.
Pineoblastoma similar to medulloblastoma.
Affects young children. Enhances avidly and is not
usually well circumscribed.
Others:
Meningioma.
Epidermoid or dermoid.
Arachnoid cyst CSF density/signal.
Pineal cyst common; fluid density or signal
though contents can be proteinaceous on MRI.
Lipoma.
Discussion
The pineal gland is a midline structure situated behind the
3rd ventricle and responsible for biorhythm. It is calcified in
most people over the age of 15 years and in almost all
92
92 Pineal germinoma.
158
Practical tips
The pineal region is in the midline and masses in this
region may compress the aqueduct of Sylvius, so
always look for associated hydrocephalus.
When the normal calcification in the pineal gland
exceeds 1 cm in diameter a pathological pineal process
should be suspected.
Calcification in germinoma when present is central, in
pineoblastoma peripheral.
In young children think of teratoma (which are very
heterogeneous masses), pineoblastoma and a vein of
Galen aneurysm.
In young adults, the most common solid lesion is a
germinoma.
Further management
Surgery is difficult due to the central location in the brain.
The main role for surgery is in obtaining a biopsy and
possibly debulking of tumour to relieve obstructive
symptoms. However, germinomas are extremely
radiosensitive and therefore radiotherapy is the mainstay
of treatment.
Case 93
CASE 93
History
A 35-year-old male patient presented
with headache.
93a
93a PD and T2 weighted axial (top), T2 weighted coronal and T1 weighted sagittal (bottom) images.
159
Answer 93
ANSWER 93
Observations (93a)
Selected MR images of the brain demonstrate
hyperintensity in the right transverse sinus on the T1 and
T2 weighted images with an absence of the normal venous
sinus flow voids. There is high-signal abnormality seen
within the right mastoid air cells on T2 weighted images,
which is intermediate signal on T1 imaging this is likely to
indicate infection/inflammatory change. Appearances are
consistent with a diagnosis of venous sinus thrombosis
secondary to mastoiditis. No intracerebral/cerebellar
haemorrhage or infarct is demonstrated on these images.
Diagnosis
Venous sinus thrombosis.
Discussion
There are a variety of underlying causes of venous sinus
thrombosis, which include trauma, infection, idiopathic and
hypercoagulable states, i.e. oral contraceptive pill,
antiphospholipid syndrome, paraneoplastic tumour
syndromes, antithrombin III deficiency. Presenting
symptoms can often be very nonspecific, meaning that
diagnosis is often only made radiologically. Symptoms
include headache, nausea, vomiting and drowsiness. The
superior sagittal sinus is most commonly affected, followed
by transverse and sigmoid sinuses.
93b
93b Selected axial CT images demonstrate a focal area of low attenuation involving grey and white matter
with appearances consistent with an infarct. The distribution, however, does not conform to arterial territories
since this represents a venous infarct.
160
Answer 93
Practical tips
Venous sinus thrombosis can present in a very
nonspecific manner and has significant morbidity and
mortality untreated. When assessing scans of acutely
neurologically unwell patients, always keep it in mind
and check the scan carefully. Similarly, beware of
dismissing infarcts that show features as described
above without questioning the possibility of an
underlying venous sinus thrombosis.
The appearances of thrombus on MRI are complex
and vary with the age of thrombus. Moreover, patent
venous sinuses can show absence of flow void when
imaged in certain planes. Making the diagnosis of
venous sinus thrombosis from MRI can therefore be
complicated. Modern multidetector CT scanners have
sufficient speed and spatial resolution to image the
venous sinuses and provide an alternative that can be
easier to interpret, thrombus appearing as a filling
defect in the lumen of the otherwise enhanced venous
sinus. Figure 93c is a coronal reformat of a CT
venogram showing thrombus in the left transverse
sinus as an empty delta sign.
Further management
Case 94
93c
CASE 94
94a
History
A 57-year-old male presented
with tinnitus and hearing loss.
161
Answer 94
ANSWER 94
Observations (94a)
Single T2 weighted MR image of the brain at the level of
the internal auditory meatus. There is a large, well defined
soft tissue mass lesion in the right cerebellopontine (CP)
angle with extension into the internal auditory canal.
Widening of the canal is seen. No dural tail is evident.
Acoustic neuroma is most likely.
Diagnosis
Acoustic neuroma.
Differential diagnosis
Of CP angle lesions:
Acoustic neuroma accounts for 75% of CP angle
masses.
Meningioma is the most likely differential at 10%
(94b). Lesions are extra-axial and tend to be
extracanalicular and commonly calcify. Dural tails are
seen in up to 60% of tumours on MRI.
94b
162
Discussion
Acoustic neuromas are the most common tumours of the
CP angle and internal auditory canal. They typically arise
from the vestibular division of the 8th nerve and should
perhaps be more accurately termed vestibular schwannomas. These lesions present in the 4th7th decades and
are more frequently seen in females. Presentation occurs
at a younger age in patients with type 2 neurofibromatosis,
with presentation in the 2nd decade. Bilateral acoustic
neuromas are virtually pathognomonic of neurofibromatosis type 2, while solitary tumours are seen in up
to 25% of cases. Presentation is with symptoms of
sensorineural hearing loss, tinnitus, vertigo and dizziness.
Answer 94
Imaging features:
80% arise in the internal auditory canal (IAC).
80% cause enlargement/erosion of the IAC.
Lesions extend into the CP angle.
Larger tumours (>3 cm) have central areas of necrosis
and haemorrhage.
Calcification is not a feature.
On CT lesions are usually isodense with uniform
enhancement.
On MRI, lesions are low signal on T1, high signal on
T2 and show uniform enhancement with gadolinium.
Practical tips
Distinguishing the main CP angle masses from each
other:
Both acoustic neuroma and meningioma show
uniform enhancement so this is unhelpful.
Acoustic neuroma expands the IAC, causing
flaring of the porus acousticus. May be bright on
T2 unlike meningioma. Makes an acute angle with
petrous bone.
Meningioma dural tail of enhancement, obtuse
angle with petrous bone. Relatively little tissue in
the IAC compared to acoustic neuroma.
Epidermoid vs arachnoid cyst both appear to
follow the density and signal of CSF on CT and T1
and T2 weighted MRI. However, the epidermoid
shows increased signal on PD, FLAIR and diffusion
weighted MRI.
CASE 95
Case 95
Further management
Therapeutic options involve surgical excision, stereotactic
radiation and conservative management. Which one
depends on the particular circumstances of each patient,
but also whether the tumour is fast growing or not. A
repeat scan a few months after the first can help identify
the group of faster growing lesions that require a more
aggressive approach.
95a
History
A 30-year-old male:
orthopantomogram
(OPG) done for dental
assessment.
163
Answer 95
ANSWER 95
Observations (95a)
The OPG shows multiple missing teeth in the upper jaw
and to a lesser extent the lower jaw too. In the right body
of the mandible, there is a well circumscribed, thin walled,
unilocular lucency measuring several centimetres in
diameter. There is no associated bony destruction. The cyst
is associated with the crown of an unerupted molar and
appearances are consistent with a dentigerous cyst.
Diagnosis
Dentigerous cyst.
Differential diagnosis
Of cystic mandibular lesion:
Periapical/radicular cyst.
Dentigerous cyst.
Odontogenic keratocyst.
Ameloblastoma.
Aneurysmal bone cyst.
Simple bone cyst.
Metastasis/myeloma.
Brown tumour.
Fibrous dysplasia.
Many other small print lesions nasopalatine cyst,
Pindborgs tumour, Stafnes bone cyst, median
mandibular cyst, etc.
Discussion
Dentigerous cysts arise from the crown of an unerupted
tooth. The typically affected age group is 1030 years, with
a male predominance. The cysts are slow growing and
usually an incidental finding, but occasionally cause pain,
swelling or become secondarily infected. The majority
occur in the posterior mandible. They are variable in size,
and have a thin walled, unilocular appearance. The
asso ciatio n with an unerupted cro wn is the key to diagno sis.
The differential diagnosis of cystic lesions of the
mandible is very long but most of the causes are so rare that
they can be dismissed most of the time. The emphasis will
consequently be on common lesions and important rare
ones. It is best to assess lesions according to visible
association with dentition, unilocular vs multilocular nature
and age of the patient. Note that although not visibly
dentition related, lesions such as ameloblastoma and
odontogenic keratocyst do arise from dental-related tissue.
95b
164
Dentition-associated cysts:
Periapical/radicular cyst secondary to pulp necrosis
of a carious tooth. Unilo cular cyst asso ciated with the
ro o t o f a to o th. Can be destructive when large, but
not expansile. Most common lesion seen. Likely to be
painful.
Dentigerous cyst unilo cular cyst asso ciated with the
cro wn o f an unerupted to o th.
No visible association with teeth:
Ameloblastoma/adamantinoma rare, locally
aggressive (but non-metastasizing) lytic tumour that
is slow growing and often painless. This is an
expansile, multilo culated cyst with bubbly
appearance (though 20% unilocular). Can be
associated with unerupted molar tooth. Thinned
cortex and no matrix mineralization. Contrast
enhanced CT/MRI may show enhancement of soft
tissue elements and possibly an enhancing mural
nodule. Five times more common in mandible than
maxilla. Typical age group 3050 years. Figure 95b is
an OPG in an adult patient with ameloblastoma
showing a lytic expansile lesion of the right side of the
mandible with areas of internal septation producing a
soap bubble appearance. The lesion is locally
aggressive and has destroyed several right lower teeth
roots.
Odontogenic keratocyst (OKC) multilo culated o r
unilo cular cyst o ften near site o f 3rd lo wer mo lar;
expansile extending along the mandible; sclerotic rim;
may displace teeth. Same age and sex group as
dentigerous cyst; 50% are symptomatic with swelling,
growth rate is rapid and recurrence rate after
curettage is high. Multiple OKCs are a feature of
GorlinGoltz (basal cell naevus) syndrome, an
autosomal dominant condition characterized by
multiple cutaneous basal cell carcinomas.
Aneurysmal bone cyst (ABC) multilo cular cyst with
so ap bubble appearance in po sterio r mandible.
Appearances are therefore very similar to
ameloblastoma but ABC occurs primarily in those
under 20 years of age.
Fibrous dysplasia ground glass matrix with
calcificatio n.
Metastases and myeloma dont forget these in the
older patient.
Answer 95
Practical tips
The cystic mandibular lesion ask yourself:
Any relation to tooth?
Multilocular or unilocular?
Age of patient?
Case 96
Further management
Multilocular cyst:
<30 years = ABC or OKC.
Multiple = OKC with Gorlin syndrome.
>30 years = ameloblastoma.
Ground glass contents OKC or fibrous dysplasia
(but matrix calcification in the latter).
Unilocular cyst with dental association:
Associated with tooth apex and pain = periapical cyst.
Associated with unerupted tooth = dentigerous cyst
(<30 years and associated with crown) or
ameloblastoma (>30 years).
Further reading
Scholl R, Kellett H, Neumann D, Lurie A (1999). Cysts
and cystic lesions of the mandible: clinical and
radiologic-histopathologic review. Radio Graphics 19:
11071124.
CASE 96
96a
History
A 30-year-old patient presented with
headaches and suspected sinusitis.
165
Answer 96
ANSWER 96
Observations (96a)
Practical tips
Discussion
Further management
Diagnosis
96b
96c
166
CASE 97
Case 97
97a
History
A 39-year-old female presented with
transient visual loss; and an episode of
ataxia 6 months ago.
97b
167
Answer 97
ANSWER 97
Observations (97a, 97b)
Selected MR images of the brain FLAIR axial and T2
weighted sagittal are presented. These scans show
multiple focal ovoid signal abnormalities in the
periventricular white matter, which are orientated
perpendicular to the long axis of the ventricles. Further
lesions involve the corpus callosum. No associated oedema.
No evidence of hydrocephalus. Given the clinical details, it
is likely that the patient has multiple sclerosis and is
currently experiencing optic neuritis.
Diagnosis
Multiple sclerosis (MS).
Differential diagnosis
Of white matter lesions on MRI:
Acute disseminated encephalomyelitis (ADEM).
Vasculitis.
Ischaemic disease (97c).
Migraine.
Neurosarcoid.
Discussion
This is the most common chronic demyelinating disease
and is characterized by multiple lesions spread in time and
space. Typically, it has a remitting /relapsing course. The
onset of symptoms is usually in the 3rd4th decades and
there is a slightly increased predominance in females.
Increased prevalence is noted in areas of temperate climate.
Clinical presentation is with focal neurological signs,
commonly including optic neuritis.
Imaging features are:
Lesions are classically periventricular in location, oval
in shape, with their long axis perpendicular to the
lateral ventricle walls Dawsons fingers.
Common locations for plaques include periventricular
white matter, corpus callosum, internal capsule,
centrum semiovale, optic nerve/tracts, cerebellum.
Lesions on the inferior aspect of the corpus callosum
are characteristic.
Acute lesions can have mild surrounding oedema and
can enhance with contrast.
Chronic lesions have no mass effect/oedema and
dont enhance.
Lesions are hyperintense on T2, hypo/isointense on
T1.
Further management
MRI of the spinal cord is frequently also undertaken to
complete assessment. Though MRI findings may be highly
suggestive, careful neurological assessment is required to
correlate the imaging findings with clinical and laboratory
findings before making the diagnosis.
Further reading
Runge VM, Price AC, Kirshner HS, et al. (1986). The
evaluation of multiple sclerosis by magnetic resonance
imaging. Radio Graphics 6: 203212.
97c
Practical tips
Focal white matter signal abnormalities in cerebral
white matter (sometimes referred to as unidentified
bright objects UBOs) are common incidental
168
CASE 98
Case 98
98a
History
A 51-year-old male presented with
chronic headaches.
98b
169
Answer 98
ANSWER 98
Observations (98a, 98b)
This lateral image of the skull (98a) shows elongation of
the jaw (prognathism), frontal bossing, enlargement of the
frontal sinuses and thickening of the calvaria. There is
marked enlargement of the pituitary fossa with evidence of
expansion but no erosion.
Selected sagittal T1 weighted images (98b) of the brain
confirm the plain film findings of enlargement of the frontal
sinuses, frontal bossing and thickening of the calvaria.
There is a mass lesion within the pituitary fossa with
appearances consistent with pituitary macroadenoma.
Enlargement of the tongue is also noted.
Practical tips
Diagnosis
Acromegaly.
Discussion
Further management
98c
98d
98e
170
98d Radiograph
of the hand
shows marked
soft tissue
enlargement
giving it a spadelike appearance.
In addition there
is widening of the
terminal tufts.
Case 99
CASE 99
History
A 22-year-old female presented with
visual field defects.
99
99 T1 weighted axial (top left), thin section T2 weighted axial orbits (top right), axial and coronal T2 weighted
(bottom) MR images.
171
Answer 99
ANSWER 99
Observations (99)
The axial images of the orbit show fusiform enlargement
of the posterior right optic nerve, which also involves both
sides of the optic chiasm. The coronal scan confirms
thickening of the posterior aspect of both optic nerves.
Axial T2 weighted images also show a round focus of high
signal in the right cerebellar hemisphere and a second lesion
in the posterior aspect of right midbrain that produces
convexity to the margins of the cerebral peduncle. The
appearances are likely to indicate optic nerve glioma
involving the chiasm and both optic nerves along with
hamartomas in the cerebellum and midbrain due to
neurofibromatosis type 1. No cutaneous neurofibromas are
seen on these images.
Diagnosis
Optic chiasm/nerve glioma due to neurofibromatosis type
1 (NF1).
Differential diagnosis
For optic nerve thickening:
Optic nerve glioma 80% under 20 years, variable
enhancement, calcification rare, buckling of nerve,
often asymptomatic.
Meningioma of optic nerve middle aged women,
tramtrack enhancement, calcification in 2050%,
straight nerve, visual impairment early.
Sarcoidosis.
Multiple sclerosis.
Lymphoma, leukaemia and metastatic disease.
Intracranial hypertension enlarges the perineural
CSF space.
Discussion
Optic nerve glioma typically presents in childhood, only
20% manifesting beyond the age of 20. Relatively slow
growing and benign in children, lesions presenting in adults
often show more rapid malignant growth with intracranial
spread. Though often asymptomatic, presentation can be
with visual loss and strabismus. Bilateral tumours herald
NF1. The tumour causes fusiform or tubular enlargement
of the optic nerve sheath complex and shows variable
enhancement with IV contrast. The majority of lesions
occurring in the orbital portion of the nerve do not extend
172
Practical tips
T1 weighted post-contrast scans of the orbit should
be performed with fat suppression in view of the
adjacent orbital fat.
Meningioma is the main differential diagnosis for
optic nerve thickening and the features listed above
may help distinguish the two.
Whenever NF1 enters the differential for any
radiological study, always check for evidence of
cutaneous nodules that clinch the diagnosis.
Further management
Treatment depends on the size of tumour along with the
age and general condition of the patient. Options include
surgery, radiotherapy and chemotherapy.
Case 100
CASE 100
History 1
A 73-year-old male presented with
acute onset of dysphagia, right sided
Horners syndrome and ataxia, with left
sided sensory disturbance.
100a
History 2
A 69-year-old female with diabetes and
hypertension presented with sudden
onset right oculomotor palsy and left
sided ataxia and tremor.
100b
173
Answer 100
ANSWER 100
Observations 1 (100a)
Axial T2 weighted image demonstrates high signal in the
lateral aspect of right medulla. This is bright on the DWI
indicating restricted water molecule diffusion probably from
cell swelling due to acute infarction. Together with the
clinical details, findings are consistent with lateral medullary
syndrome due to infarction in the territory of the right
posterior inferior cerebellar artery (PICA).
Observations 2 (100b)
These axial and coronal T2 weighted images show a focus
of increased signal in the right side of the midbrain. There
is no associated mass effect and the lesion lies in the region
of the red nucleus. The clinical symptoms are compatible
with an infarct affecting the red nucleus and causing
Claudes syndrome.
Diagnosis 1
Right PICA infarction (Wallenbergs syndrome).
Diagnosis 2
Right midbrain infarction affecting the red nucleus
(Claudes syndrome).
Discussion
There are various specific patterns of brainstem infarction,
often having unusual eponyms. Others include Webers,
Nothnagels, MillardGubler and Fovilles syndromes.
Wallenbergs syndrome is due to PICA occlusion and
presents with ipsilateral ataxia, dysphagia, facial pain and
temperature sensory impairment and Horners syndrome,
with contralateral impairment of pain and temperature
sensation in the body and limbs. The PICA is the first
major intracranial branch of the vertebrobasilar system and
supplies the dorsolateral medulla, cerebellar vermis and
posterolateral cerebellar hemisphere. It arises from the distal
vertebral artery just below the basilar artery origin. As well
174
Practical tips
These are examples of comparatively rare and very
specific infarcts but they do make for an interesting
test of neuroanatomy understanding!
DWI depicts reduction in Brownian motion of water
molecules. Cytotoxic oedema in acute infarction will
produce this and present high signal on the DWI
scan. It is very sensitive, depicting infarcts just 30 min
or so from onset.
The DWI image also has inherent T2 weighting (T2
shine through), that is, the signal is a combination
of T2 weighted and reduced diffusion. As such, it
may not distinguish an older infarct (T2 hyperintense)
from a recent one (reduced diffusion) as both will
appear bright. An alternative depiction that can
differentiate acute and nonacute infarcts is the
apparent diffusion coefficient (ADC) map. This has
no T2 component and shows reduced diffusion (i.e.
acute infarct) as low signal. An older infarct that is
also bright on DWI by virtue of T2 shine through
will be bright on ADC.
Ischaemia is not the only cause of reduced diffusion.
Others include seizure, trauma, hypoglycaemia,
abscess.
Further management
DWI is more sensitive in the early detection of infarction
when compared to CT. However, when thrombolysis is
being considered, CT is more than adequate to exclude a
haemorrhage alone.
100a
100b
CASE 101
Case 101
101a
History
A 32-year-old male presented with
poorly controlled epilepsy.
101b
175
Answer 101
ANSWER 101
Observations (101a, 101b)
The axial CT image of the brain (101a) shows several small
calcified lesions in the subependymal region of the body of
the lateral ventricles. The T2 weighted MR image of the
brain (101b) confirms several small subependymal nodules
with associated low signal representing calcification. These
appearances are consistent with subependymal hamartomas.
There are abnormal widened gyri in the left parietal lobe
and right frontal lobe seen on the MR image, which are
likely to indicate cortical hamartomas.
Diagnosis
Tuberous sclerosis.
Further management
Tuberous sclerosis has a high mortality with 70% dying
before the age of 24 years. A multidisciplinary team
approach is required with follow-up imaging involving
MRI brain, renal ultrasonography (monitoring angiomyolipomas and looking for renal cell carcinomas) and
echocardiography (50% of patients have rhabdomyomas).
Discussion
Tuberous sclerosis is an inherited autosomal dominant
disorder of the neuroectoderm that is characterized by
multisystem abnormalities. The classical triad of features
are mental retardation, seizures and adenoma sebaceum.
CNS features:
Subependymal hamartomas most commonly seen
along the ventricular surface of the caudate nucleus.
Multiple small subependymal lesions which calcify in
80%. Figure 101c shows another case where nodules
have not calcified, but produce a wavy border to the
ventricle walls.
Cortical tubers appearances are of large widened
atypical gyri with reduced attenuation centres on CT.
They are usually multiple and can show rim
calcification in 50%.
Heterotopic grey matter islands these appear as large
hypodense focal islands of tissue within the cerebral
white matter.
Giant cell astrocytomas occur around the foramen of
Monro, and can cause hydrocephalus. Malignant
potential is low.
Further reading
Altman NR, Purser RK, Post MJ (1988). Tuberous
sclerosis: characteristics at CT and MR imaging.
Radio lo gy 167: 527532.
101c
Multisystem involvement:
Ocular ocular phakomas, optic nerve gliomas.
Renal angiomyolipoma, cysts, increased risk of renal
cell carcinoma.
Respiratory lymphangiomyomatosis-like features
with cystic lung disease, spontaneous pneumothoraces
and chylothorax.
Cardiovascular rhabdomyoma, aortic aneurysms.
Skin adenoma sebaceum (red/brown small flat skin
lesions distributed symmetrically over nose and
cheeks), shagreen patches, ash leaf lesions, subungual
fibromas.
Practical tips
The phakomatoses (neurocutaneous disorders), of
which tuberous sclerosis is an example, make great
exam cases because of the multitude of radiological
signs to piece together know them well!
176
Case 102
CASE 102
History
Adult patient presented with recent
onset of seizures.
102a
177
Answer 102
ANSWER 102
Observations (102a)
Axial T2 (left) and gradient echo T2 (right) images
demonstrate a lesion in the medial right temporal lobe with
a very low signal rim representing haemosiderin. This is
characteristically more prominent on the gradient echo T2
sequence with blooming artefact. The centre of the lesion
shows T2 hyperintensity and the overall shape is round.
The features are consistent with a cavernoma.
Diagnosis
Cavernoma (cavernous angioma or cavernous malformation).
Discussion
Vascular malformations are a common cause of
parenchymal brain haemorrhage and should be excluded
when young patients present with spontaneous
haemorrhage. They develop from congenitally abnormal
vascular connections, which may increase in size with time.
Radiological features of vascular malformations are:
Arteriovenous malformations (AVMs) are the most
common type and are essentially an abnormal
collection of arteries connected directly to veins with
no intervening capillaries (102b). The vast majority
are supratentorial. On CT they are of mixed density
and may have calcifications. Enhancement is also seen.
However, the classical appearance is found on MRI
102b
Practical tips
AVMs typically have a tangle of low-signal flow voids
on MRI best seen on T2 and PD weighted imaging.
10% of AVMs develop an associated aneurysm so
always look for this.
Gradient echo T2 is an excellent technique for
identifying haemosiderin on MRI, which is often seen
in vascular malformations.
102c
178
Answer 102
Case 103
Further management
Often these are asymptomatic and can be monitored with
imaging to assess change in growth. There is, however, an
up to 2% risk of bleeding and surgery/stereotactic
radiosurgery are treatment options.
102d
CASE 103
History
A 65-year-old male presented with
swelling and impaired vision of the left
eye.
103
103 Axial and coronal T2 weighted scans of orbits (left/middle) and a time of flight MR angiogram of the
intracranial circulation (right).
179
Answer 103
ANSWER 103
Observations (103)
T2 weighted images demonstrate dilatation of the left
superior ophthalmic vein with presence of flow void and
no focal compressive mass lesion. The time of flight MRA
demonstrates normal arterial intracranial anatomy with
signal in the dilated left ophthalmic vein indicating fast
flow. The findings are in keeping with a left caroticocavernous fistula.
Diagnosis
Caroticocavernous fistula.
Differential diagnosis
For superior ophthalmic vein distension:
Cavernous sinus thrombosis.
Superior ophthalmic vein thrombosis.
Pseudotumour.
Graves disease.
Obstructive orbital mass.
Practical tips
Discussion
Fistulous communication between the internal carotid
artery and the cavernous sinus can arise secondary to head
trauma or rupture of an internal carotid artery aneurysm.
The condition often occurs spontaneously, however, due
to atherosclerosis. In addition, fistulae can occur with dural
branches of the external carotid artery. Orbital bruit is
found in ~50% of patients due to turbulent arterial blood
flow. The increased arterial pressure in the venous system
and orbital vein congestion result in the symptoms of:
Pulsatile proptosis.
Chemosis.
Reduced visual acuity due to impaired retinal
perfusion severe/rapid visual loss requires
angiographic investigation and fistula closure as an
emergency to preserve function.
103
180
Further management
When imaging features of a caroticocavernous fistula are
associated with decreased visual acuity, emergency treatment is required to relieve intraocular pressure.
Case 104
CASE 104
History
A 32-year-old male presented with
headaches and new onset epilepsy.
104
104 MRI T1 and T2 weighted axials (top) and T1 weighted post IV gadolinium axial and sagittal (bottom).
181
Answer 104
ANSWER 104
Observations (104)
Selected MR images of the brain show a large lesion in the
cerebellum, which is predominantly cystic in nature
(hyperintense on T2 and hypointense on T1 weighted
images). Following IV contrast there is enhancement of the
wall of the cystic component and an associated solid nodule
posteriorly. Sagittal image shows some fullness of the lateral
ventricles and obstructive hydrocephalus is likely with
compression at the level of the 4th ventricle.
Diagnosis
Haemangioblastoma.
Differential diagnosis
Juvenile pilocytic astrocytoma can be very difficult to
differentiate from a haemangioblastoma. This is the
most common infratentorial tumour in children.
There is an association with neurofibromatosis type 1.
Lesions are of an identical appearance, with a
predominant cystic component and enhancing solid
peripheral nodule.
Metastasis.
Atypical medulloblastoma.
Discussion
Haemangioblastoma is a benign vascular tumour affecting
the CNS. It is the most common primary infratentorial
tumour in adults. The majority (80%) present in adults in
the 3rd6th decades, although there is an association with
von HippelLindau (VHL), which sees these tumours
presenting in childhood and in this case may be multiple.
Practical tips
When forming a differential for the posterior fossa cystic
mass with enhancing peripheral nodule, the following
generalizations apply:
Children pilocytic astrocytoma >
haemangioblastoma.
Younger adults haemangioblastoma most common.
Older adults consider cystic metastasis.
Further management
When haemangioblastoma is suspected, dont forget to
raise the possibility of VHL (420% of haemangioblastoma
occur in the context of VHL and multiple lesions are
diagnostic of VHL). VHL is an autosomal dominant (AD)
inherited condition characterized by a predisposition to
develop a spectrum of tumours including haemangioblastomas, cardiac rhabdomyomas, renal cell carcinomas,
pheochromocytomas, pancreatic cystadenocarcinomas, islet
cell tumours and haemangioblastomas, liver haemangiomas
and retinal angiomas.
104
182
Case 105
CASE 105
History
A 28-year-old male of no fixed abode,
presented with a short history of
confusion and limb weakness.
105
105 T1 sagittal (top left) and T2 weighted images (top right and bottom).
183
Answer 105
ANSWER 105
Observations (105)
The selected images demonstrate diffuse cerebral atrophy
exceeding that expected for the patients young age. There
is a large focal area of signal abnormality in the central pons
that is hyperintense on T2 weighted and hypointense on
T1 weighted scans. There is no associated mass effect. The
signal changes would fit with central pontine myelinolysis
and the clinical details and cerebral atrophy suggest that
chronic alcohol abuse may be the underlying cause.
Practical tips
Diagnosis
Differential diagnosis
Pontine glioma.
Infarction.
Further management
Discussion
Central pontine myelinolysis results from the destruction
of myelin sheaths, classically in patients with rapidly
corrected hyponatraemia. Cases are reported in patients
with:
Chronic alcohol abuse.
Chronic liver disease.
Severe malnutrition.
Wilsons disease, chronic renal failure, diabetes, acute
myelogenous leukaemia.
In the case demonstrated there is diffuse global cerebral
atrophic change suggestive of chronic alcohol abuse.
Further reading
Ruzek KA, Campeau NG, Miller GM (2003). Early
diagnosis of central pontine myelinolysis with
diffusion-weighted imaging. American Jo urnal o f
Neuro radio lo gy 25: 210213.
Stadnik TW, Demaerel P, Luypaert RR, et al. (2003).
Imaging tutorial: differential diagnosis of bright
lesions on diffusion-weighted MR images.
Radio Graphics 23(1): e7.
105
105 Focal area of reduced signal on T1 weighted (left) and increased signal on T2
weighted (right) images.
184
CASE 106
106a
History
A 49-year-old female patient presented
with headaches.
CASE 107
History
A 2-year-old female presented with
developmental delay.
(see page 188 fo r case answer)
107a
107a T1 weighted sagittal (left) and T2 weighted axial and coronal (middle/right) images.
185
Answer 106
ANSWER 106
Observations (106a)
This non contrast enhanced CT image demonstrates a large
midline mass extending into the 3rd ventricle, which has
both solid and cystic components with central calcification.
There is dilatation of the temporal and anterior horns of
the ventricles but normal appearance to the 4th ventricle
findings are in keeping with obstructive hydrocephalus at
the level of the 3rd ventricle secondary to a mass lesion.
The mixed density and calcification are very suggestive of
a craniopharyngioma and MRI is suggested to further
evaluate.
Diagnosis
Craniopharyngioma.
Differential diagnosis
Of suprasellar/intrasellar mass lesion:
Pituitary macroadenoma.
Craniopharyngioma.
Rathke cleft cyst.
Other masses in the sellar region include meningioma,
metastases, chordoma and internal carotid artery aneurysm.
Pituitary macroadenoma is the most common lesion
involving the sellar and suprasellar regions. Microadenomas
(20%) are defined as being less than 10 mm in size and
usually present with symptoms due to hormonal secretion.
Macroadenomas (80%) measure over 10 mm in size and
are usually endocrinologically inactive. They present with
symptoms secondary to mass effect such as hydrocephalus,
bitemporal hemianopia from optic chiasm compression,
involvement of cranial nerves travelling in the adjacent
Discussion
Craniopharyngioma account for ~4% of intracranial
neoplasms, with a slight predominance in males, and two
peaks of increased incidence:
Firstly in children in 1st2nd decades, where they
account for 50% of suprasellar tumours.
Secondly in adults in 5th 6th decades.
These are benign tumours arising from remnants of
Rathkes pouch. They grow from a suprasellar origin into
the base of the 3rd ventricle. Intrasellar extension occurs
in 21%. Involvement of the bony sella can be seen on plain
radiographs and on CT bone window images. These
demonstrate appearances of J-shaped sella, enlarged sella
and then ultimately erosion and destruction.
106b
106b Pre- and post-contrast T1 weighted MR sagittal images demonstrate a large pituitary
adenoma with uniform enhancement with contrast and with no cystic elements or signal
voids to suggest calcification.
186
Answer 106
Practical tips
Look for the complications of mass lesions in this area:
Hydrocephalus and optic chiasm compression.
Lateral extension to involve the cavernous sinus (seen
in up to 10% of pituitary macroadenomas), which can
lead to thrombosis and cranial nerve palsy. Lateral
extension beyond the lateral wall of the internal
carotid is rare with Rathke cleft cyst and may help
differentiate it from the other two conditions listed.
Further management
Treatment is surgical +/ postoperative radiotherapy.
Further reading
Choi SH, Kwon BJ, Na DG, et al. (2007). Pituitary
adenoma, craniopharyngioma, and Rathke cleft cyst
involving both intrasellar and suprasellar regions:
differentiation using MRI. Clinical Radio lo gy 62:
453462.
106c
106c T1 sagittal pre- and post-IV contrast and T2 axial and sagittal images demonstrate a
large suprasellar lesion with solid and cystic elements with enhancement of the solid
components and cyst wall. The lesion is causing obstructive hydrocephalus, pituitary stalk
and optic chiasm compression.
187
Answer 107
ANSWER 107
Observations (107a)
T1 sagittal and T2 axial and coronal images of the brain
demonstrate complete agenesis of the corpus callosum with
no callosal tissue identified. There is increased separation
of the lateral ventricles on the axial images creating a bats
wing appearance. Coronal image demonstrates elevation
of the 3rd ventricle.
Diagnosis
Practical tips
Discussion
The corpus callosum usually develops by 20 weeks
gestation. The genu and the body of the corpus callosum
develop first and the posterior body and splenium develop
later. The rostrum is the last part of the corpus callosum to
develop. Identifying the parts of the corpus callosum
present can help to differentiate between dysgenesis (absent
genu/splenium) and destruction, most commonly due to
ischaemia (genu present but may be atrophic). Corpus
callosal agenesis is usually associated with reduced
intellectual function and can be associated with a variety of
CNS abnormalities including hydrocephalus, midline
lipoma, DandyWalker cysts, interhemispheric arachnoid
cysts, neuronal migration disorders and ArnoldChiari
malformation.
Classical imaging appearances on CT/MRI are with:
Bats wing appearance of the lateral ventricles due to
parallel lateral ventricles with marked separation
(107b).
High riding 3rd ventricle can be seen at the level of
the lateral ventricles.
Enlarged foramen of Monro.
Further management
Sometimes this finding is made incidentally on brain
imaging in later life and no further investigation is
required.
Further reading
Babcock DS (1984). The normal, absent, and abnormal
corpus callosum: sonographic findings. Radio lo gy
151: 449453.
Davidson HD, Abraham R, Steiner RE (1985). Agenesis
of the corpus callosum: magnetic resonance imaging.
Radio lo gy 155: 371373.
107b
107b Axial CT images of the brain demonstrating bats wing appearance of the lateral ventricles in a patient
with agenesis of the corpus callosum.
188
Case 108
CASE 108
History
A 38-year-old female presented with
left sided tinnitus and hearing loss.
108a
108b
189
Answer 108
ANSWER 108
Observations (108a, 108b)
Axial CT images (108a axial CT scan at skull base with
IV contrast, seen on bone and soft tissue windows) of the
brain demonstrate a poorly defined enhancing lesion in the
jugular foramen, which is extending superiorly to involve
the middle ear and is causing permeative erosion of the
petrous temporal bone at the jugular foramen. The T2
weighted MR image (108b) confirms this mass lesion,
which appears hyperintense with serpiginous flow voids
indicating vascular flow.
Diagnosis
Practical tips
Description
Glomus jugulare tumours are paragangliomas and are the
most common jugular foramen lesion. Typically, these
lesions are solitary with a peak incidence in the 5th6th
decades and increased incidence in females. There are
familial associations in which multiple paragangliomas
present in conditions such as multiple endocrine neoplasia
(MEN).
Glomus jugulare tumours usually extend intracranially
and can involve the middle ear, as demonstrated here.
Clinical presentation may be related to involvement of the
9th, 10th and 11th cranial nerves. When there is extension
to involve the middle ear (glomus jugulotympanicum) then
pulsatile tinnitus is the classical presentation.
These tumours are highly vascular and enhance avidly
with contrast on CT and MRI. On CT, permeative bone
erosion is classical, differing from the coarser lytic
Further management
Depending on the size of the tumour and the intracranial
extension, a combined ENT/neurosurgical procedure is
performed.
Further reading
Caldemeyer KS, Mathews VP, Azzarelli B, Smith RR
(1997). The jugular foramen: a review of anatomy,
masses, and imaging characteristics. Radio Graphics
17: 11231139.
108b
190
Case 109
CASE 109
History
A 24-year-old female presented with
chronic headaches and visual loss.
109
109 T1 weighted sagittal and coronal (top) and T2 weighted coronal (bottom) MR images.
191
Answer 109
ANSWER 109
Observations (109)
These selected MR images show an expanded sphenoid
sinus filled with abnormal signal rather than air. The
contents show mild uniform hyperintensity on T1 weighted
and T2 weighted images. The walls of the sinus appear
smooth and intact with no obvious evidence of destruction.
The findings are consistent with a mucocele of the
sphenoid sinus, the signal indicative of proteinaceous fluid
contents. Sagittal T1 and coronal T2 images demonstrate
displacement of the optic nerves by the expanded sinus,
presumably causing compression of the anterior optic
pathway given the history of visual disturbance.
Diagnosis
Sphenoid sinus mucocele.
Discussion
A mucocele arises due to chronic obstruction of a sinus,
which then becomes filled with mucus. This collection acts
like a slow growing mass causing expansion of sinus bony
walls without frank bony destruction. Vessels and other
structures are displaced rather than being encased, as with
a tumour. Usually these lesions are asymptomatic until they
become large when they can cause optic nerve compression,
proptosis and headache. Secondary infection of the
mucocele can supervene, but this is a rare complication.
Ninety per cent of lesions are found in the frontal and
ethmoid sinuses with sphenoid sinus mucoceles being only
rarely seen.
Practical tips
CT is good for showing bony expansion with the
absence of bone erosion.
MRI is good for identifying the extent/size of the
lesion and looking for complications of optic nerve
compression (usually from posterior ethmoid lesions)
and proptosis (usually from frontal and anterior
ethmoid sinuses).
T1 hyperintensity within a lesion on any MRI study
often helps to rapidly limit the differential diagnosis as
there are a limited number of things that are bright
on T1 imaging, i.e. fat, blood, proteinaceous fluid,
paramagnetic contrast agents.
Further management
Referral to ENT for consideration of endoscopic sinus
surgery.
109
109 Superior displacement of optic nerve (left); lateral displacement of cavernous sinus
by large sinus mucocele (right).
192
CASE 110
Case 110
110a
History
A 68-year-old female
presented with worsening
headaches.
110b
193
Answer 110
ANSWER 110
Observations (110a, 110b)
The selected plain CT images (110a) show a poorly
defined, hyperdense midline lesion extending across the
body of the corpus callosum. There is no significant
surrounding oedema.
Pre- and post-contrast T1 weighted MR images (110b)
from the same patient show a multilobulated lesion with
uniform enhancement crossing the midline in the body of
the corpus callosum. No further lesions are seen within the
brain parenchyma. Incidental note is made of cavum
septum pellucidum. The findings are of a butterfly tumour
in the corpus callosum.
Diagnosis
Butterfly glioblastoma multiforme (GBM).
Practical tips
GBM and lymphoma are the two likeliest diagnoses for
butterfly lesions involving the corpus callosum. Although
difficult to differentiate radiologically, cavitation and
necrosis are relatively uncommon in lymphoma (except in
AIDS patients).
Differential diagnosis
For lesions crossing the midline in the corpus callosum:
GBM.
Lymphoma.
Demyelinating disease multiple sclerosis.
Discussion
This is the most common and the most malignant primary
brain tumour. It accounts for >50% of brain tumours with
a wide age distribution peaking at the 7th8th decades. The
most common location is within the white matter of
centrum semiovale with increased incidence in the frontal
lobes. Other patterns of distribution include callosal
extension giving this appearance of a butterfly glioma,
posterior fossa lesions and multifocal distribution (seen in
24%).
Tumours spread by direct extension involving white
matter tracts, such as the corpus callosum and cerebral
peduncles or via the CSF (<2% of cases). Haematogenous
spread can also very rarely occur.
Further management
T2 hypointensity is sometimes present with CNS
lymphoma and therefore this image sequence can
sometimes help to differentiate lymphoma from
glioblastoma.
Neurosurgical evaluation.
Further reading
Bourekas EC, Varakis K, Bruns D, et al. (2002). Lesions
of the corpus callosum: MR imaging and differential
considerations in adults and children. American
Jo urnal o f Radio lo gy 179: 251257.
Rees JH, Smirniotopoulos JG, Jones RV, Wong K
(1996). Glioblastoma multiforme: radiologicpathologic correlation. Radio Graphics 16: 6.
110a
110a Lobulated lesion crossing the midline in the body of the corpus callosum.
194
CASE 111
111a
Case 111
111b
History
A 33-year-old male presented with
lower back pain.
111c
195
Answer 111
ANSWER 111
Observations (111a, 111b, 111c)
These STIR sagittal (111a), STIR coronal (111b) and T2
weighted axial (111c) images of the spine demonstrate
posterior vertebral scalloping, particularly at the T11, T12
and L2 levels. There is also a thoracic scoliosis. At
approximately T10 level, coronal images show a right sided
high-signal lesion projecting laterally from the spinal canal,
presumably through the intervertebral foramen. This
follows CSF signal and is probably a lateral thoracic
meningocele. The axial T2 weighted image shows a second
lateral thoracic meningocele on the left side, in a similar
region of the spine. The combination of findings is strongly
suggestive of neurofibromatosis type 1 and multiple highsignal cutaneous nodules on the sagittal images confirm this
diagnosis.
Diagnosis
Neurofibromatosis type 1 (NF1).
Discussion
Neurofibromatosis type 1 is a neurocutaneous disorder, of
which 50% is inherited in an autosomal dominant manner
and 50% is sporadic. Classical features in the spine include:
Lateral thoracic meningocele (dysplasia of the
meninges resulting in diverticula of the thecal sac,
which extends through the neural foramina).
Posterior vertebral scalloping also due to dural
ectasia.
111a
111a Posterior
vertebral
scalloping.
Practical tips
Always look for the presence of subcutaneous nodules
on the image when NF1 is suspected.
It may be difficult to differentiate between a lateral
thoracic meningocele and a dumbbell neurofibroma.
However, on MRI the former will be of CSF density
on all sequences, i.e. high signal on T2, whereas the
latter will have a hyperintense periphery on T2 with a
hypointense core.
In a case such as this, one might also comment that
there are no obvious adrenal masses or renal
asymmetry (implying association with
phaeochromocytoma and renal artery stenosis,
respectively).
Further management
Neurofibromas can undergo malignant transformation in
23%; therefore a rapid rate of growth or new onset pain
should be thoroughly investigated.
111b
196
Case 112
CASE 112
History
A 22-year-old female had had persistent
headache for several days. There was no
history of trauma.
112a
197
Answer 112
ANSWER 112
Observations (112a)
Selected unenhanced axial CT images of the brain show a
well defined low attenuation lesion in the left frontal lobe
causing minimal mass effect. The contents are of lower
attenuation than CSF but given the absence of trauma it is
unlikely that this is due to intracranial air. It is likely that
instead, it represents fat, which could be easily confirmed
by adjusting the CT windows or taking a direct density
measurement. A calcified nodule is seen at the posterior
aspect of the lesion with further mural calcifications
elsewhere. Further small locules of fat are seen in the
anterior horn of the left lateral ventricle and several sulci.
Diagnosis
Practical tips
Discussion
Dermoid cysts are fairly uncommon CNS lesions, usually
presenting before the 4th decade. They arise due to
inclusion of epithelial elements at the time of closure of the
neural tube and therefore contain ectodermal and
mesodermal components, i.e. hair, sebaceous glands and
skin. Dermoids are usually located near the midline and can
be found within brain parenchyma, ventricles, CSF spaces
or within bone. Development and growth are very slow and
presentation is therefore late.
Typical appearances on CT: low-density lesions
containing fat with no contrast enhancement. Mural
or focal central calcification can be seen.
Further management
MRI is better than CT for identifying rupture of a dermoid
cyst and the consequent chemical meningitis.
112b
198
Case 113
CASE 113
History
A 45-year-old patient presented with
confusion developing over 1 week.
113a
199
Answer 113
ANSWER 113
Observations (113a)
These T2 weighted axial brain images show a diffuse
increase in signal affecting the right temporal lobe. This
involves grey and white matter, extending to the cortical
surface. Sulci in the affected area are effaced. Similar signal
changes extend along the cingulate gyrus and also affect
the contralateral temporal lobe to a lesser extent. The
duration of the history and distribution of involvement are
in keeping with encephalitis, most likely due to herpes
simplex virus.
Diagnosis
Herpes simplex (HSV) encephalitis.
Differential diagnosis
Right middle cerebral territory infarct.
Discussion
Encephalitis is the term generally used to describe a diffuse
cerebral inflammatory process of viral aetiology. Clinical
presentation is with confusion, headache and seizures
progressing to coma. Fever is almost always present. The
most common organism is HSV, infection being either
primary or due to virus reactivation. The resulting cytotoxic
oedema manifests as high signal on T2 weighted, FLAIR
and DWI MRI. The temporal lobe is typically affected,
often with the inferior frontal lobe and cingulate gyrus.
Unlike other viral infections, the basal ganglia are usually
spared.
Further management
Urgent treatment with antiviral drugs mortality in
untreated HSV encephalitis can be as high as 65%.
Practical tips
HSV encephalitis has high mortality and morbidity
rates but is treatable with acyclovir so a high index of
suspicion is needed, especially on CT, which may well
be the first imaging done signs of oedema and
swelling are likely to be comparatively subtle
compared to MRI (if present at all).
113b
200
Answer 113
Case 114
113c
CASE 114
114a
History
A 36-year-old male was brought to
A&E in cardiorespiratory arrest. No
other history is available.
201
Answer 114
ANSWER 114
Observations (114a)
This single CT image shows diffuse low-attenuation change
in the frontal and temporal lobes and brainstem with loss
of the greywhite matter differentiation. The cerebellum is
better preserved. Generalized sulcal effacement indicates
cerebral swelling.
This widespread reduction in brain density makes the
normal cerebral vessels and dural reflections appear
spuriously conspicuous. Close inspection confirms that this
is a perceptual abnormality the basal cisterns are of
normal CSF density so there is not acute subarachnoid
haemorrhage. The findings are suggestive of global cerebral
ischaemia and oedema.
Diagnosis
Global cerebral anoxia.
This particular case turned out to be secondary to
asthma-induced cardiorespiratory arrest.
Discussion
Global ischaemia can occur following prolonged hypoxia,
which may be secondary to fitting, aspiration, smothering,
strangulation, etc. The CT findings are distinctive, with loss
of greywhite matter differentiation and changes due to
cerebral oedema including sulcal effacement. Generalized
low density of the cerebral cortex develops. The cerebellum
114b
202
Answer 114
Practical tips
Dont mistake cerebral anoxic change for SAH in the
unconscious patient check that the hyperdensity
really is in the subarachnoid space and not a
perceptual illusion from cerebral anoxia.
Always remember that a normal CT scan does not
exclude SAH, especially as the time interval from onset
of symptoms increases. If the CT is normal, LP
looking for xanthochromia is required (this may be
evident in CSF after 24 hr but can only be
conclusively excluded if the LP is done at least 12 hr
after onset).
Remember that SAH can be secondary to trauma as
well as leaking aneurysm, etc.
When SAH is present, the site of aneurysm is likely to
be where there is most blood!
Further management
Regarding suspected SAH, a negative CT alone is
insufficient to exclude the diagnosis. LP (looking for
xanthochromia) is required in cases where CT is normal.
This should be delayed for at least 12 hr from the onset of
headache as false negatives may occur before this time.
114c
203
Chapter 4
MUSCULOSKELETAL
IMAGING
Much of the advice given here relates to the plain
radiograph, though the fundamental principles can often
be applied to CT and MRI too. When analysing a musculoskeletal film, check the bones, the joints and the soft tissues.
There may be obvious abnormalities at first inspection but,
as always, a systematic check of all three areas will ensure
nothing is missed.
In the real world, the radiologist is usually made aware
of a history of trauma but this may not be provided in a
viva. There are certain diagnoses that must not be missed
on the chest radiograph (e.g. tension pneumothorax) and
abdominal film (e.g. viscus perforation) due to the gravity
of the consequences for the patient (and the viva candidate,
who will fail as a result!). Similarly in MSK imaging,
fractures must not be missed. One should therefore always
be on guard for subtle fractures when nothing else is
apparent, especially those such as the unstable cervical spine
injury where the consequences of nonrecognition are
serious.
Musculoskeletal imaging is one area in particular where
there are many Aunt Minnie diagnoses disorders with
classical appearances that rely on recall from previous
experience rather than a systematic analysis. In the real
world, some such conditions are important to recognize so
as to avoid unnecessary further investigation. In a viva, they
represent easy points for those who have spent time
preparing well!
BONES
Aggressive vs benign
This is a very important decision with regards to clinical
management of focal bone lesions. Note the use of the
term aggressive rather than malignant while malignant
bone lesions are often aggressive, nonmalignant pathology
such as infection can also behave in an aggressive manner.
Location
As well as the obvious question of which bone is affected,
the part of the bone affected (epiphysis, metaphysis or
diaphysis) also helps one to narrow down the differential
diagnosis. For example, an aggressive lesion with a
permeative appearance in the diaphysis of a young patient
might be a Ewings sarcoma but the same type of appearance in the metaphysis would raise the possibility of
osteosarcoma instead. An expansile lesion seen within the
pelvis would have a different differential to an expansile
lesion seen in the axial skeleton.
205
Musculoskeletal Imaging
Age
Age is vitally important in forming a differential diagnosis
for focal bone lesions, as the probability of many lesions
varies dramatically between young and older people. For
the purposes of radiological assessment of focal bone
lesions, one might consider less than 30 years of age as
being young and over 40 as older! For example, many
benign bony lesions such as simple bone cyst and
aneurysmal bone cyst are really only seen in the younger
age group. Similarly, there are certain primary bone
malignancies also seen primarily in this age group, e.g.
Ewings sarcoma. Conversely, metastases are relatively
common in the older age group and consequently often
enter the differential diagnosis.
JOINTS
Arthropathy is a very common radiological problem in the
real world and in examinations. Pattern recognition of the
more common varieties is aided by exposure to as many
films as possible but thereafter, first principles can be used
when in doubt.
The do-not-miss lesion involving the joints is septic
arthritis be suspicious of this when presented with a case
in which there is a single joint showing features of joint
space narrowing, erosion of bone on both sides of the joint
and soft tissue swelling.
Subchondral sclerosis, geodes and osteophytosis are
features of degenerative disease, while osteopenia, soft
tissue swelling and erosions are common features of
inflammatory arthropathy. Joint space loss is seen in both,
so is not usually helpful in discriminating the two.
Other features to assess are the distribution axial vs
appendicular skeleton, small vs large joints, distal vs
206
SOFT TISSUES
Though more readily assessed on MRI, it is easy to forget
the soft tissues on plain films. However, swelling around
a bone may guide you to underlying fracture or
osteomyelitis, while swelling around a joint may point to
arthropathy or intra-articular fracture for example.
Musculoskeletal Imaging
CASE 115
Case 115
115a
History
A 13-year-old male presented with pain
in his left arm following a fall.
207
Answer 115
Musculoskeletal Imaging
ANSWER 115
Observations (115a)
This radiograph demonstrates a well defined lucent lesion
of the proximal metaphysis of the left humerus. The lesion
is centrally located with slight thinning of the cortex, mild
expansion and several internal septae. It has a narrow zone
of transition. There is a pathological fracture through the
lesion with associated periosteal reaction and a fallen
fragment sign. The features are consistent with a benign
lesion, specifically a simple bone cyst.
Diagnosis
Simple bone cyst (SBC).
Differential diagnosis
The fallen fragment sign is supposedly very specific for
SBC, but otherwise, possibilities include:
Aneurysmal bone cyst (ABC) 1030 year olds.
Occurs in the metaphysis +/ epiphysis. Like a simple
bone cyst it is a well defined lucency with an intact
cortex. This is typically an expansile lucent lesion. An
example is shown in the pelvis of a child (115b).
Giant cell tumour (GCT) seen in 2035 year olds.
Subarticular, eccentric location within epiphysis
(metaphysis if growth plate open). Cortical
destruction can occur and rarely metastases to the
lungs.
Brown tumour.
Fibrous dysplasia.
Enchondroma.
Discussion
Simple (unicameral) bone cysts are benign lesions usually
(75%) located in the proximal humerus and femur. They
occur in patients aged 515 years and are more commonly
found in males (ratio 3:1). Typical imaging features are
demonstrated with the lesion seen in the metaphysis,
however they gradually migrate to the diaphysis as the
bones grow (115c). They are asymptomatic unless
pathological fracture occurs and a small fragment of bone is
115b
208
115c
Practical tips
A detailed discussion of all the possible focal lucent bone
lesions is beyond the scope of this case discussion and the
reader is advised to consult the relevant chapter in one of
the many excellent textbooks available. However, a few
words of advice can be given on how to approach the
problem and some basic guidelines regarding this case:
Know the age of the patient (this may be obvious
from the radiograph, for example if there are unfused
epiphyses). Over the age of 40, metastases and
myeloma become common and can show benign
features so often end up high on the list of
possibilities. Conversely, a young age immediately
skews the differential towards benign pathology.
Does the lesion have aggressive or nonaggressive
features? Bear in mind that aggressive does not
necessarily mean malignant as certain pathologies
such as infection can look aggressive. Aggressive
features include cortical destruction/breakthrough,
the presence of lamellated, spiculated or hair on end
periosteal reaction and a wide zone of transition (i.e.
poorly defined margins). Permeative lesions (multiple
small holes with no perceptible border and a wide
zone of transition) also tend to indicate malignancy.
Shown as an example is the pelvic radiograph (115d)
in an elderly female with metastases from breast
carcinoma; these lytic deposits are affecting the
majority of the right hemipelvis, the left ilium and
both femoral necks. In fact, there is a pathological
fracture of the left femoral neck. Note how the lesions
have a wide zone of transition and evidence of cortical
destruction with aggressive periosteal reaction, i.e. all
the features of an aggressive pathology. This contrasts
markedly with the nonaggressive features of the ABC
(115b).
115c Sagittal T2
weighted MRI image
shows a well defined
high signal cystic
lesion in the
proximal left femur.
Answer 115
Musculoskeletal Imaging
Further management
None is necessary. Most spontaneously regress with age.
Pathological fractures commonly occur and may need
fixation.
Case 116
115d
CASE 116
History
A 40-year-old male patient with left hip pain.
116a
209
Answer 116
Musculoskeletal Imaging
ANSWER 116
Observations (116a)
There is right femoral head resurfacing in this patient.
Arthropathy of the left hip is seen with loss of joint space
and subchondral cysts. Sacroiliac joints are not well
demonstrated but there is the suspicion of fusion along
with ossification in the midline along the interspinous
ligaments. There is also arthropathy at the pubic symphysis
and whiskering at the ischial tuberosities in keeping with
enthesopathy. The features are characteristic of ankylosing
spondylitis.
Diagnosis
Ankylosing spondylitis.
Differential diagnosis
Of sacroiliitis on plain film:
Ankylosing spondylitis.
Inflammatory bowel disease.
Hyperparathyroidism tends to cause sacroiliac joint
widening due to bone resorption.
Rheumatoid.
Gout.
Psoriatic arthropathy.
Reiters syndrome.
Osteoarthritis (OA).
Infection TB.
Practical tips
Discussion
Ankylosing spondylitis is an autoimmune seronegative
arthropathy primarily affecting young males and
predominantly involving the spine. Syndesmophyte
formation and ossification of spinal ligaments leads to
ankylosis and stiffness. Bilateral symmetrical sacroiliitis is
116b
116c
210
Answer 116
Musculoskeletal Imaging
Case 117
116d
Further management
Treatment of ankylosing spondylitis is supportive, one in
five patients progressing to significant disability. Ulcerative
colitis and aortitis are associations. One per cent of patients
develop upper zone lung fibrosis, which can be complicated
by superinfection with aspergillus. Death may occur from
cervical spine fracture or aortitis.
Further reading
Levine D, Forbat S, Saifuddin A (2004). MRI of the axial
skeletal manifestations of ankylosing spondylitis.
Clinical Radio lo gy 59: 400413.
CASE 117
117a
History
A 13-year-old male presented
with pain in his left hip.
211
Answer 117
Musculoskeletal Imaging
ANSWER 117
Observations (117a)
This AP radiograph in an unfused skeleton shows widening
of the growth plate of the left hip with a slight decrease in
height of the left femoral epiphysis compared to that on
the right. Also, Kleins line does not intersect the femoral
epiphysis on the left. The appearances are consistent with
a slipped left upper femoral epiphysis. A frog lateral should
be done to check if there is a subtle slip on the right.
Further reading
Boles C, El-Khoury G (1997). Slipped capital femoral
epiphysis. Radio Graphics 17(4): 809823.
Diagnosis
Slipped upper femoral epiphysis (SUFE).
Discussion
Atraumatic fracture through the hypertrophic zone of the
physeal plate results in a slipped capital femoral epiphysis.
It is the most common abnormality of the hip in
adolescence with an incidence of 2 in 100,000. It is
thought to occur due to widening of the epiphyseal plate
during growth spurt with change in the orientation of the
physis leading to an increase in shear forces. Affected
patients tend to be overweight teenaged males. The mean
age affected is 13 years for boys and 11 years for girls,
corresponding to the growth spurts. The condition is
associated with delayed skeletal maturation after
adolescence and is bilateral in 20%. Hip pain is the most
common presenting symptom with knee pain affecting a
quarter of all cases.
Radiographs show:
Apparent reduction in height of the femoral epiphysis.
Irregularity of the growth plate.
Kleins line does not intersect the femoral epiphysis.
The apparent reduction in epiphyseal height on the AP
radiograph is due to the direction in which it slips, most
commonly posteromedial. The line of Klein is drawn along
the superior edge of the femoral neck and should intersect
part of the epiphysis in a normal hip. Figure 117b shows
Kleins lines drawn on this childs film note how the left
line fails to intersect the epiphysis. These features may all
be very subtle on the AP radiograph and therefore a frog
lateral should always be performed when the diagnosis is
suspected. The frog lateral will often accentuate the
findings and may also confirm a subtle slip in the
contralateral hip. The frog lateral in this case (117c)
confirms the slip, which is more obvious than on the
anteroposterior film.
117b
117c
Practical tips
When assessing radiographs of childrens hips, the likely
pathologies can be easily predicted from the childs age:
48 years Perthes; 817 years SUFE.
Further management
If untreated, slipped capital femoral epiphysis can result in
avascular necrosis (AVN) of the femoral head with
consequent osteoarthritis, a debilitating condition when
acquired at such a young age. The risk of AVN increases
the larger the degree of slip and the longer the delay to
surgery. It is therefore of paramount importance that it is
not missed on imaging. Treatment involves pinning the
epiphysis to the femoral neck, sometimes with osteotomy
212
Musculoskeletal Imaging
CASE 118
Case 118
118a
History
A male patient presented with pain in
amputation stump.
213
Answer 118
Musculoskeletal Imaging
ANSWER 118
Observations (118a)
Discussion
Diagnosis
Lymphoma recurrence following amputation.
Differential diagnosis
Of permeative bone lesions:
Metastases.
Myeloma.
Lymphoma.
Leukaemia.
Osteomyelitis.
118b
Practical tips
This is an example of a viva type film where there is no
definite or spot diagnosis to be made it is simply a case
of presenting a reasoned approach to a sensible differential
diagnosis, then stating how this could be narrowed down
using clinical information or further investigations.
Further management
Recurrence of lymphoma may entail further surgery
and/or radiotherapy. MRI may be helpful to assess the
local extent more accurately.
118c
214
Musculoskeletal Imaging
CASE 119
History
A 4-year-old boy presented with a
suspected chest infection.
119a
CASE 120
History
A 62-year-old female presented
with neck pain.
120a
215
Answer 119
Musculoskeletal Imaging
ANSWER 119
Observations (119a)
Discussion
Diagnosis
Osteopetrosis.
Differential diagnosis
Of osteosclerosis in children:
Osteopetrosis.
Pyknodysostosis.
Renal osteodystrophy.
Hypervitaminosis D.
Hypervitaminosis A.
Fluorosis.
Of Erlenmeyer flask deformity (mnemonic Lead
GNOME):
Lead.
Gauchers.
NiemannPick disease.
Osteopetrosis.
Metaphyseal dysplasia (Pyles) and craniometaphyseal
dysplasia (same as Pyles disease but there is a history
of cranial nerve palsies).
Ematological!! thalassaemia.
119b
216
119b Radiograph
of femur in same
child shows
diffuse
osteosclerosis
with widening of
the distal femoral
diametaphysis, i.e.
Erlenmeyer flask
deformity.
Practical tips
For osteosclerosis in children:
Erlenmeyer flask deformity, sandwich vertebrae and
bone within bone appearance point to osteopetrosis.
Pyknodysostosis is associated with multiple wormian
bones. As with osteopetrosis, pathological fractures
may be seen (119c). A hand radiograph in another
119c
119c Diffuse
osteosclerosis
with a
pathological
fracture of the
tibia in a patient
with
pyknodysostosis.
Musculoskeletal Imaging
Further management
The only treatment available for osteopetrosis is bone
marrow transplantation. Patients are more prone to
fractures than the normal population.
119d
Pyknodysostosis
hand showing
osteosclerosis with
pointing of the
distal phalanges
producing a
pointed chalk
appearance.
119d
119e Forearm of a
patient with
fluorosis showing
diffuse
osteosclerosis and
prominent
ligamentous
insertion
calcification.
119e
ANSWER 120
Observations (120a)
Lateral flexion and extension views of the cervical spine are
shown. On flexion there is significant atlantoaxial joint
subluxation. The odontoid peg is not clearly demarcated
and is likely to be partially eroded. The remainder of the
cervical spine is quite well preserved. The most likely
diagnosis in a patient of this age is rheumatoid arthritis.
Diagnosis
Atlantoaxial subluxation in a patient with rheumatoid
arthritis (RA).
Differential diagnosis
Of atlantoaxial subluxation:
RA.
Psoriatic arthropathy.
Juvenile idiopathic arthritis.
Ankylosing spondylitis.
Systemic lupus erythematosus (SLE).
Downs syndrome.
Morquios syndrome.
Retropharyngeal abscess in a child.
Discussion
Atlantoaxial subluxation occurs when the distance between
the posterior aspect of the arch of the atlas and the anterior
aspect of the odontoid peg exceeds 3 mm in adults and 5
mm in children. Erosion and destruction of the odontoid
peg may also be seen, particularly when the process is
caused by an inflammatory arthropathy. Several causes are
described in the differential diagnosis list but RA is the
most common cause in adults. Synovitis with pannus
formation causes erosion of the odontoid peg and
atlantoaxial ligaments and consequent subluxation. This
(co nt.)
217
Answer 120
Musculoskeletal Imaging
Practical tips
Look for other signs of RA in the neck.
Bamboo spine suggests ankylosing spondylitis.
Posterior vertebral scalloping and anterior vertebral
beaks in Morquios.
Soft tissue swelling in a child consider abscess.
Further management
Clinical assessment and measurement of serum markers
such as rheumatoid factor are required. To confirm the
findings on plain radiography one might consider MRI of
the cervical spine to assess the soft tissue component of the
disease. Atlantoaxial subluxation may be managed
surgically or conservatively with a stiff collar depending on
the particular circumstances. The anaesthetist is often
particularly interested in excluding this complication in
rheumatoid patients as it presents an obvious hazard
during preoperative airway intubation.
Further reading
Sommer O, Kladosek A, Weiler V, et al. (2005).
Rheumatoid arthritis: a practical guide to state-of-theart imaging, image interpretation, and clinical
implications. Radio Graphics 25: 381398.
120b
120c
218
Musculoskeletal Imaging
CASE 121
Case 121
121a
History
A young Afro-Caribbean patient
presented with left knee pain.
121b
219
Answer 121
Musculoskeletal Imaging
ANSWER 121
Observations (121a, 121b)
Tumoral calcinosis.
Differential diagnosis
Practical tips
Discussion
Further management
Diagnosis
121c
121e
121f
121d
121d
Radiograph of
the left hip of a
child with
periarticular
calcification
arising from a
synovial
sarcoma.
121g
121e, 121f, 121g Axial T1, T2 and fat saturated images of the synovial sarcoma shows a fairly well defined
soft tissue lesion which is of low signal on T1 and inhomogeneously high signal on T2.
220
Musculoskeletal Imaging
CASE 122
122a
History
A 40-year-old presented with knee
discomfort.
CASE 123
123
History
Male patient presented with rigidity and
kyphosis.
221
Answer 122
Musculoskeletal Imaging
ANSWER 122
Observations (122a)
Practical tips
Diagnosis
Further management
No further management is normally necessary. Both these
conditions are usually found incidentally. The main thing
is to ensure that a patient with multiple sclerotic lesions
has osteopoikilosis and not sclerotic metastases.
Further reading
Differential diagnosis
Sclerotic metastases in a patient with melorheostosis; this
is much less likely. However in patients with multiple
sclerotic foci alone, sclerotic metastases must always be
considered.
Discussion
Melorheostosis is a nonhereditary disease of unknown
aetiology that often presents as an incidental finding. It is
usually discovered in childhood where it has a rapid
progression, but it occasionally presents in adults where it
has a slow chronic course. The limb involved often
demonstrates joint pain, swelling and limitation of
movement. Males and females are equally affected.
Radiological signs of melorheostosis are as follows:
Cortical hyperostosis in one or multiple tubular bones
with streaks of sclerosis beginning at the proximal end
of the bone and extending distally. This produces the
characteristic dripping candle wax appearance. This is
shown particularly well in Figure 122b, where the
right humerus and scapula are affected in another
patient.
Predominantly affects the diaphysis of the bone.
The lower extremities are more commonly affected
than the upper.
Although a single bone may be involved, contiguous
bones of an extremity are more often affected.
Bilateral signs are extremely rare and should prompt
consideration of other causes of sclerosis.
Limb length discrepancy is also a feature and the
sclerosis may cross the joint and result in joint fusion.
The skull, spine and ribs are rarely involved. Melorheostosis
is associated with osteopoikilosis, osteopathia striata
(asymptomatic disease consisting of longitudinal striations
along the metaphyses of long bones) and arteriovenous
malformations.
Osteopoikilosis is an autosomal dominant disorder that
is more common in males. It is asymptomatic and consists
of multiple ovoid bone islands parallel to the long axis of
the bone. These bone islands normally measure 210 mm
and are found at the metaphysis and epiphysis, rarely
extending into the midshaft. It usually affects the pelvis,
wrist and ankle and rarely affects the skull, ribs and
mandible. The differential diagnosis of this condition,
which often leads to clinical confusion and concern, is
disseminated sclerotic metastases.
222
122b
122b AP radiograph of
melorheostosis affecting the
humerus and scapula
demonstrating the typical
dripping candle wax appearance.
Answer 123
Musculoskeletal Imaging
Case 124
ANSWER 123
Observations (123)
This AP radiograph of the pelvis reveals thick linear
columns of calcification and ossification around both hips
and in the paravertebral regions bilaterally. The hip joints,
sacroiliac joints and spine are fused. The patient has had
previous internal fixation of the left hip. The appearances
are in keeping with myositis ossificans progressiva.
Diagnosis
Myositis ossificans progressiva.
Discussion
This is an Aunt Minnie. Myositis ossificans progressiva is
also known as fibrodysplasia ossificans progressiva. It is a
rare slowly progressive disease characterized by
exacerbations and remissions of fibroblastic proliferation
leading to ossification and calcification of skeletal muscle,
subcutaneous fat, tendons and ligaments.
Radiological features are:
Linear columns of ossification and calcification.
Ossified bridges between different bones.
Ankylosis.
Kyphosis due to rigidity of the muscles of the spine
and upper limbs.
CASE 124
Practical tips
Ossified bars and bridges between bones are the hallmark
of this rare condition.
Further management
Treatment is supportive. Attempts at surgery to relieve
rigidity have led to accelerated ossification at the surgical
site.
124a
History
A child presented with retarded
growth.
223
Answer 124
Musculoskeletal Imaging
ANSWER 124
Observations (124a)
Further management
Further reading
Diagnosis
Thalassaemia major.
Discussion
Thalassaemia is an inherited disorder of haemoglobin
synthesis characteristically seen in Mediterranean patients.
The homozygous form, thalassaemia major, is more severe.
The radiological signs result from marrow hyperplasia and
expansion due to extramedullary haematopoiesis. Every part
of the skeleton may be affected in patients with untreated
disease. Radiological features of the complications of
treatment such as recurrent transfusions and iron chelation
therapy may also be seen. In fact, abnormalities secondary
to iron chelation therapy are now more common than
those due to marrow hyperplasia.
The radiological signs to look for depend on the site of
the body imaged:
Peripheral skeleton:
Coarse trabeculation causing cobweb appearance
(124a).
Loss of concavity of tubular bones (124a).
Erlenmeyer flask deformity of metaphyses of long
bones (124a).
Arthropathy and chondrocalcinosis as a result of
haemochromatosis secondary to hypertransfusion.
Fraying of metaphyses and dense metaphyseal
bands secondary to iron chelation therapy.
Skull:
Hair on end appearance.
Frontal bossing (124b) due to diploic expansion.
Obliteration of paranasal sinuses (except for
ethmoid sinuses) due to marrow hyperplasia
(124b).
124b
124c
Axial skeleton:
Coarse trabeculation causing cobweb appearance
(124c).
Biconcave vertebrae.
Bone within bone appearance of spine and ribs.
Paraspinal masses (due to extramedullary
haematopoiesis).
Expansion of the ribs posteriorly, particularly at the
costochondral junctions, due to marrow hyperplasia
(124c).
Practical tips
The only sign may be a diffuse but subtle coarsening
of the bony trabeculae.
On an AXR look for evidence of hepatosplenomegaly
(a result of extramedullary haematopoiesis) and
gallstones.
On a CXR look for cardiomegaly secondary to
anaemia, as well as a paraspinal mass due to
extramedullary haematopoiesis.
224
Musculoskeletal Imaging
CASE 125
Case 125
125a
History
A 10-year-old child presented with leg
pain and fever.
225
Answer 125
Musculoskeletal Imaging
ANSWER 125
Observations (125a)
There is a mostly sclerotic lesion arising in the diaphysis of
the proximal fibula in this unfused skeleton. This has a wide
zone of transition and demonstrates a florid hair on end
periosteal reaction. The features are in keeping with an
aggressive lesion. Ewings sarcoma and osteosarcoma are
the two main differential diagnoses and the patient should
be referred urgently to a specialist unit.
Diagnosis
Ewings sarcoma.
Differential diagnosis
Osteosarcoma.
Discussion
Ewings sarcoma is the most common malignant bone
tumour in children, with a peak age of 15 years. Most
patients (96%) are Caucasian with a male to female ratio of
1:2. These are round cell tumours and are clinically,
radiologically and histologically very similar to primitive
neuroectodermal tumours (PNET). Patients present
clinically with severe pain that may be associated with a soft
tissue mass. Fever and leukocytosis are also features. Long
bones are affected in the majority of cases and this usually
affects the diaphysis of the bone rather than the metaphysis
(which is the more common site of involvement for
osteosarcoma). Flat bones such as the pelvis and ribs are
affected in 40% of cases and this is predominantly seen in
older patients, whereas younger patients tend to present
with long bone lesions. In most cases the lesion is lytic
rather than dense and there is often a permeative moth
eaten appearance. Invasion into local soft tissues is seen in
up to a half of cases and there is usually an aggressive
periosteal reaction causing a sunburst or hair on end
appearance. A Codmans triangle may also be seen.
These features can all be seen in osteosarcoma and
sometimes it can be difficult to differentiate the two
conditions radiologically. A radiograph of the right femur
and knee in a 12-year-old boy with osteosarcoma is shown
(125b). This can be seen as a sclerotic density with a wide
zone of transition in the metadiaphysis of the distal femur,
with aggressive periosteal reaction. Overall, the appearances
are quite similar to those seen in Figure 125a and both
diseases have a similar 6080% 5 year survival rate. The
practical tips section below lists some features that may help
differentiate the two.
Practical tips
In assessing focal bone lesions, the first concern is
whether the lesion is benign or aggressive (note that
aggressive lesions are not necessarily malignant
infection, for example, can cause aggressive
appearances). One of the most important factors is the
clarity and extent of the margin between the lesion
and adjacent normal bone, the so-called zone of
transition. A wide zone of transition indicates an
indistinct and extended junction between lesion and
normal bone, and is a hallmark of the aggressive
226
125b
125b AP knee
radiograph in a
12-year-old child
demonstrates a
sclerotic lesion of the
femoral metaphysis
that has a wide zone
of transition and
aggressive periosteal
reaction. This proved
to be an
osteosarcoma.
Answer 125
Musculoskeletal Imaging
Case 126
Further management
MRI is helpful in assessing local spread and aids planning
of surgical resection.
Further reading
Murphey M, Robbin M, McRae G, et al. (1997). The
many faces of osteosarcoma. Radio Graphics 17:
12051231.
Ewings sarcoma
Children
More common in diaphysis
More commonly lucent or permeative
To bone
CASE 126
Osteosarcoma
Older children and young adults
More common in metaphysis
More commonly sclerotic
To lung
126a
History
A 35-year-old male presented with
shoulder pain.
227
Answer 126
Musculoskeletal Imaging
ANSWER 126
Observations (126a)
Practical tips
Diagnosis
Osteomalacia.
Discussion
Osteomalacia is a disorder of insufficient osteoid
mineralization causing bone softening. Aetiology can be
due to dietary deficiency, decreased absorption or deficient
metabolism of vitamin D.
Radiological features of osteomalacia include:
Generalized osteopenia.
Cortical thinning.
Bowing of long bones.
Protrusio acetabuli.
Coarse trabecular pattern (126b).
Looser zones:
Pseudofractures that consist of transverse lucent
clefts with sclerotic margins.
These are mostly seen in the pelvis, femoral necks
(126c) and scapula.
Further management
Treatment involves reversing the cause of vitamin D
deficiency.
Insufficiency fractures.
126b
126c
228
Musculoskeletal Imaging
CASE 127
History
A 5-year-old child presented with
marked bowing deformity of right leg.
127a
CASE 128
128
History
A young adult with nail
abnormalities.
229
Answer 127
Musculoskeletal Imaging
ANSWER 127
Observations (127a)
There is marked angulation deformity of the diaphyses of
the lower tibia and fibula with the formation of
pseudarthroses. The bones are also generally osteopenic.
The most likely diagnoses are nonunion of previous
fractures, neurofibromatosis or osteogenesis imperfecta.
Diagnosis
Neurofibromatosis.
Differential diagnosis
Nonunion of a fracture.
Osteogenesis imperfecta.
Fibrous dysplasia.
Congenital.
Discussion
Congenital affects the middle to lower third of the tibia
and fibula. Half of congenital pseudarthroses present in the
first year of life and later on there may be cupping of the
proximal bone end and pointing of the distal bone end.
Neurofibromatosis type 1 (NF1) is a common genetic
disorder and in addition to cutaneous and neurological
abnormalities, osseous lesions are also seen. There may be
anterolateral bowing of the tibia with or without a
hypoplastic fibula. Focal narrowing and intramedullary
sclerosis or cystic change at the apex of the angulation is
due to hamartomatous fibrous tissue, typically at the
junction of the middle and distal third of tibia. Pathological
fracture with nonunion often results in pseudarthrosis of
the tibia and fibula, with pencil pointing of the bone
fragments. Prophylactic bracing of limbs with bowing
deformity may prevent the development of pseudarthrosis.
Osteotomy with bone grafting and pinning (127b) is the
treatment of choice if the pseudarthrosis has already
occurred.
127b
230
Practical tips
Severe osteopenia and multiple fractures of differing
ages that have exuberant callus formation suggest
osteogenesis imperfecta. Remember that some
osteopenia may result from disuse, however, e.g. in
fracture nonunion.
Look for soft tissue nodules indicative of
neurofibromatosis.
A ground glass density lesion associated with the
pseudarthrosis is suggestive of fibrous dysplasia.
Further management
As in this case, osteotomy with bone grafting and pinning
is the treatment of choice.
Further reading
Cheema J, Grissom L, Harcke H (2003). Radiographic
characteristics of lower-extremity bowing in children.
Radio Graphics 23: 871880.
Answer 128
Musculoskeletal Imaging
Case 129
ANSWER 128
Observations (128)
There are bilateral posterior iliac horns consistent with
Fongs disease.
Diagnosis
Fongs disease.
Practical tips
Discussion
This case is an Aunt Minnie. Fongs disease, also known as
nailpatella syndrome and osteo-onychodysplasia, is a rare
autosomal dominant disorder characterized by symmetrical
ectodermal and mesodermal anomalies. Patients tend to
present with abnormalities of nail dysplasia that can
manifest as spooning and splitting of the fingernails or even
hypoplasia or aplasia. This particularly affects the thumb
and index fingernails. Patients may also have abnormal
pigmentation of the iris.
The presence of bilateral posterior iliac horns is seen in
80% of cases and is diagnostic of the condition. Hypoplasia
of the anterior half of the ilia can result in drooping of the
iliac crests. The other major finding is aplasia or hypoplasia
of the patellae, which frequently results in recurrent lateral
CASE 129
Further management
The most serious association of this condition is renal
dysfunction, which occurs secondary to abnormality of the
glomerular basement membrane leading to proteinuria,
haematuria and renal failure. The exact mechanism for this
is unknown, but renal failure tends to occur in later life.
This is an important point to note when diagnosis of this
condition is made, often incidentally.
129a
History
A patient presented with head injury.
231
Answer 129
Musculoskeletal Imaging
ANSWER 129
Observations (129a)
Practical tips
Diagnosis
Thalassaemia major.
Differential diagnosis
Of hair on end appearance of skull:
The mnemonic is STAN and is easy to remember when
you think of Stan Laurels hair!
Sickle cell disease.
Thalassaemia major.
Anaemia (other anaemias):
Hereditary spherocytosis.
Glucose-6-phosphate dehydrogenase deficiency.
Severe iron deficiency anaemia.
Neoplastic:
Haemangioma (129b).
Neuroblastoma metastases in children.
Further management
Thalassaemia major has a poor prognosis with most
affected children not surviving past the first decade.
Treatment is by repeated transfusions.
Further reading
Hollar M (2001). The hair-on-end sign. Radio lo gy 221:
347348.
Discussion
The hair on end sign is a finding that can be seen in the
diploic space of the skull on radiographs, CT and MRI, and
has the appearance of long, thin, vertical striations. On plain
radiographs and CT the appearance is caused by alternating
thickened trabeculae and radiolucent marrow hyperplasia.
On MRI, the alternating bands of hypointense trabeculae
and hyperintense marrow produce the distinct striated
pattern. Essentially the effect is due to marrow hyperplasia.
The diploic space widens and the outer table thins and can
become obliterated. With regard to anaemic causes, the
marrow hyperplasia begins in the frontal region and can
affect the entire calvaria excluding that which is below the
internal occipital protuberance, since there is no marrow in
this area. Marrow hyperplasia in thalassaemia major is more
marked than in any other anaemia and may cause
hyperplasia of the facial bones resulting in obliteration of
the paranasal sinuses. However the ethmoid sinuses are
spared as they do not contain marrow. The hair on end
appearance can also be seen in severe childhood cases of
iron deficiency anaemia.
The medical literature is split as to whether the hair on
end appearance may be reversed following treatment of
the anaemia. Some authors have reported that resolution
of the appearance occurs with treatment, although the
diploic space may remain wider than normal. However
others have reported that the appearances persist without
regression even over a follow-up period of approximately
20 years.
232
129b
Musculoskeletal Imaging
CASE 130
130a
History
A 45-year-old male presented with left
sided chest pain for several weeks. He
had suffered minor trauma to the arm.
CASE 131
131a
History
A 20-year-old male presented
with knee pain.
233
Answer 130
Musculoskeletal Imaging
ANSWER 130
Observations (130a)
Multiple bony exostoses are seen arising from the ribs on
both sides of the chest. On the left, there is a large
associated soft tissue mass projected over the lateral thorax.
Given the history of chest pain, sarcomatous transformation
must be suspected. Moreover, there is a small left pleural
reaction, a large pulmonary nodule in the left upper zone
and possible pulmonary nodules in the left lower zone and
right costophrenic recess.
The combination of findings suggests sarcomatous
transformation in diaphyseal aclasis with pulmonary
metastases.
Diagnosis
Diaphyseal aclasis with sarcomatous transformation.
Discussion
Diaphyseal aclasis is an autosomal dominant condition
characterized by multiple exostoses (osteochondromas).
Osteochondromas are benign cartilaginous tumours.
Diaphyseal aclasis is usually discovered in childhood and
short stature may occur due to the development of
exostoses at the expense of normal bone growth. The
exostoses are usually multiple and bilateral and mostly affect
the limbs though ribs can be affected, as in this case. The
234
Practical tips
Diaphyseal aclasis is a misnomer as the exostoses
arise from the metaphyses.
They are often multiple and bilateral and point away
from the nearest joint.
The cartilage cap of the exostosis may be calcified.
Further management
In cases of nerve entrapment, surgical excision may be
possible. The crucial factor is to identify malignant
degeneration when it occurs; suspicious signs include pain
and growth of an exostosis after physeal closure and
thickening of the cartilaginous cap by greater than 1.5 cm.
This is best delineated on MRI.
130b
130c
Answer 131
Musculoskeletal Imaging
Case 132
ANSWER 131
Observations (131a)
Practical tips
Differential diagnosis
Further management
Spontaneous osteonecrosis.
Diagnosis
Discussion
Osteochondritis dissecans is synonymous with
osteochondrosis dissecans and osteochondral fracture
(131b). The cardinal feature is fragmentation of a portion
of the articular cartilage and underlying bone, which may
separate to form a loose body within the joint. It is thought
to occur due to subchondral fatigue fracture as a result of
shearing from rotatory impaction forces. Though
sometimes asymptomatic, presentation is often with pain
aggravated by movement and/or limited movement.
Patients are most commonly affected in adolescence with
males affected more than females. The typical location of
osteochondritis dissecans at the knee is the Lateral Aspect
of Medial femoral Epicondyle (usefully remembered by the
LAME mnemonic). The condition can be bilateral in up
to 30% of cases. Other commonly affected sites include the
humeral head, capitellum and talus. MRI is useful in
determining whether the osteochondral fragment is loose
as evidenced by a rim of fluid around it on T2 weighted
images or a rim of contrast around it on MRI arthrography.
CASE 132
131b
132a
History
A middle aged female presented with
painful hands.
235
Answer 132
Musculoskeletal Imaging
ANSWER 132
Observations (132a)
This radiograph of both hands reveals soft tissue swelling
at the metacarpophalangeal joints bilaterally and to a lesser
extent at the proximal interphalangeal joints. This is not
associated with any erosions, however there is subluxation
of several joints including the metacarpophalangeal joint of
the right index finger and the right first carpometacarpal
joint. Degenerative changes are also noted at both wrists.
In summary, there is a bilateral nonerosive arthropathy with
evidence of joint subluxation. The differential diagnosis
includes collagen vascular disease. Early rheumatoid arthritis
should also be considered.
Diagnosis
Systemic lupus erythematosus (SLE).
Jaccouds arthropathy.
Hypogammaglobulinaemia.
Discussion
Further management
Differential diagnosis
Of nonerosive deforming arthropathy:
Collagen vascular disease.
SLE.
EhlersDanlos syndrome.
Scleroderma.
132b
236
Practical tips
132c
Musculoskeletal Imaging
CASE 133
Case 133
133a
History
A 15-year-old male presented with left
shoulder pain.
237
Answer 133
Musculoskeletal Imaging
ANSWER 133
Observations (133a)
AP and axial radiographs of the left shoulder demonstrate
a well defined lesion in the upper humeral epiphysis. This
has a thick sclerotic border and central lucency. The lesion
has nonaggressive features including a narrow zone of
transition and the likely diagnosis considering the age of
the patient and the location of the lesion is
chondroblastoma.
Further management
Diagnosis
Chondroblastoma.
Differential diagnosis
Of epiphyseal lesions:
Chondroblastoma well defined sclerotic border,
calcification in 50%, may have periosteal reaction.
Giant cell tumour (GCT) closed epiphyses, abuts
articular surface, eccentric, no marginal sclerosis. No
periosteal reaction unless fracture present.
Geode will be other signs of arthropathy; older
patients.
Metastases and myeloma.
Infection usually metaphyseal rather than epiphyseal.
133b
133c
Discussion
Chondroblastoma is a rare, cartilage containing tumour
that almost always occurs in the epiphyses of long bones.
Patients affected are under 30 years of age and tend to
present with localized pain. The lesion is usually well
defined with a sclerotic border and occurs most commonly
about the knee joint. Calcification within the lesion is seen
in approximately 50%. The tumour rarely metastasizes but
may be locally aggressive (133b, 133c).
As with all focal bone lesions, an assessment of benign
vs aggressive features, the patients age and the location of
the lesion within the bone are critical in forming a
meaningful differential diagnosis. Fortunately, the
differential for epiphyseal lesions is fairly short! One
condition that deserves brief discussion is GCT as this can
sometimes look similar. The vast majority occur in long
bones, most commonly at the knee. Age at presentation is
2040 years, often with pain. Classical features of GCT are
presence in a fused skeleton, epiphyseal subarticular
location, eccentric position and absence of marginal
sclerosis. Only when all these features are present can one
confidently predict GCT from the plain radiograph. What
is impossible to say, however, is whether the lesion is
benign or malignant.
Figure 133d is a radiograph of the knee in a patient with
a GCT. Note how the lesion abuts the articular surface but
has no marginal sclerosis unlike the chondroblastoma
illustrated (133a). The distinction may not always be this
clear however, and further advice is offered in the practical
tips section.
133d
Practical tips
With regard to epiphyseal lesions in young patients,
the two main possibilities are chondroblastoma and
GCT. However, many chondroblastomas will not have
the prominent internal calcifications and sclerotic
border seen in Figure 133a. In such cases it is
238
Musculoskeletal Imaging
CASE 134
134
History
A 25-year-old male presented with knee
pain and fever.
CASE 135
135
History
A 28-year-old male with bilateral hip
pain.
239
Musculoskeletal Imaging
ANSWER 134
Observations (134)
AP and lateral radiographs of the right knee reveal a well
demarcated area of lucency in the metaphysis of the
proximal tibia. This is surrounded by sclerosis and there is
no evidence of extension through the growth plate into the
epiphysis. A small amount of smooth periosteal reaction is
seen medially. Together with the history of pyrexia, the
findings best fit with the diagnosis of Brodies abscess.
Diagnosis
Brodies abscess.
Differential diagnosis
Osteosarcoma.
Giant cell tumour (GCT) (in child).
Discussion
Brodies abscess is the term used to describe a subacute
pyogenic osteomyelitis. It is a smouldering, indolent
infection that is most commonly caused by Staphylo co ccus
aureus. Children and males are more commonly affected.
It has a predilection for the ends of tubular bones and is
characteristically located in the metaphysis. The proximal
and distal metaphyses of the tibia are the most common
sites involved. The carpal and tarsal bones are other
commonly affected sites. The characteristic appearance is
of a central area of lucency surrounded by a dense rim of
reactive sclerosis. A lucent, tortuous channel extending
towards the growth plate is pathognomonic when seen.
Periosteal reaction and new bone formation are features
and there may be adjacent soft tissue swelling. On MRI, a
Practical tips
Giant cell tumour in children is often located in the
metaphysis rather than its characteristic epiphyseal
location in adults. Therefore GCT in children may
look like a Brodies abscess when marginal sclerosis is
limited.
In more subtle cases where the abscess is present near
the cortex of a bone, the lesion may mimic an osteoid
osteoma.
In difficult cases where the abscess is not well defined,
the appearances may look like those of a malignant
process and when considering the metaphyseal
location of the disease the findings may look
suspicious of an osteosarcoma. This is where local
periosteal reaction is important and if smooth rather
than aggressive, will suggest benign disease.
Further management
Treatment is surgical drainage.
Further reading
Rosenberg Z, Beltran J, Bencardino J (2000). MR
imaging of the ankle and foot. Radio Graphics 20:
S153S179.
ANSWER 135
Observations (135)
Differential diagnosis
Of irregular epiphyses:
Avascular necrosis.
Multiple epiphyseal dysplasia.
Meyers dysplasia.
Morquios syndrome.
Congenital hypothyroidism.
Chondrodysplasia punctata.
Diagnosis
Meyers dysplasia with secondary synovial osteochondromatosis.
240
Discussion
Meyers dysplasia, also known as congenital multicentric
ossification of the femoral heads, is an epiphyseal dysplasia
that is confined to the upper femoral epiphyses. The
femoral heads become irregular, fragmented and collapsed,
leading to premature degenerative joint disease. It can be
an incidental finding in asymptomatic hips of young
Answer 135
Musculoskeletal Imaging
CASE 136
Case 136
Practical tips
Multiple epiphyseal dysplasia will be seen in other
joints and there may be a family history. Meyers is
confined to the hips.
When irregular/stippled epiphyses identified:
Look for ancillary signs of avascular necrosis:
Signs of sickle cell anaemia, e.g. endplate
infarctions of the vertebral bodies, and
gallstones on an AXR.
Associations with steroid therapy on a pelvic xray/AXR, e.g. thumb-printing in colon, stoma
bag or sacroiliitis.
Associations with condition of
immunosuppression on a pelvic x-ray, e.g. pelvic
transplant kidney.
Look for ancillary signs of Morquios syndrome:
Posterior vertebral scalloping.
Anterior vertebral body beaks.
Further management
Treatment is supportive. Joint replacement may be needed
in the long term.
136a
History
A 32-year-old male presented with
thigh pain.
241
Answer 136
Musculoskeletal Imaging
ANSWER 136
Observations (136a)
Practical tips
Diagnosis
Further reading
Parosteal osteosarcoma.
Differential diagnosis
Further management
Surgical resection can result in an 8090% 10 year survival
rate, the best prognosis of all types of osteosarcoma.
Osteochondroma.
Extraosseous osteosarcoma.
Juxtacortical haematoma.
Myositis ossificans.
Discussion
Parosteal osteosarcoma accounts for 4% of all
osteosarcomas. The tumour originates in the outer layer of
periosteum and is slow growing. Eventually, invasion of the
medullary canal may occur. Fifty per cent of patients are
more than 30 years of age when affected, with the peak at
38 years. This contrasts with conventional osteosarcoma,
where 75% are younger than 30 years of age. Females are
more commonly afflicted at a ratio of 3:2. The lesion most
commonly affects the posterior aspect of the distal femur. It
also affects either end of the tibia, the proximal humerus
and the fibula, but is rare in other long bones. The
metaphysis is the most common part of the long bone that
is affected and the patient may present with a palpable mass.
The typical radiological appearances are of a lobulated
cauliflower-like ossific mass extending away from the
cortex. In over a third of cases a fine radiolucent line
separates the tumour mass from the cortex and this is
known as the string sign. The attachment to the cortex is
described as the tumour stalk, and when considering
differential diagnoses this will not be seen with myositis
ossificans. Non-aggressive periosteal reaction is also a
feature. Another example is shown in a child in Figure
136b.
A medullary canal mass with aggressive periosteal
reaction (e.g. sunburst or hair on end) points to
conventional osteosarcoma. These features are demonstrated in the typical metaphyseal location in a knee
radiograph of a child with osteosarcoma (136c).
Conventional osteosarcoma affects males more commonly
than females and there is a bimodal age distribution with
elderly patients being affected due to malignant transformation in Pagets disease. Parosteal osteosarcoma has the
best prognosis of all osteosarcomas with an 8090% 10 year
survival rate (6080% for conventional osteosarcoma).
242
136b
Answer 136
Musculoskeletal Imaging
Case 137
136c
CASE 137
137a
History
A 58-year-old female presented with
back pain.
243
Answer 137
Musculoskeletal Imaging
ANSWER 137
Observations (137a)
There is homogeneous sclerosis of the L4 vertebral body
producing the appearance of an ivory vertebra. No
significant expansion or trabeculation of the vertebral body
is seen. The remaining vertebrae and bony skeleton are
normal in appearance. The most likely diagnosis in a female
patient is sclerotic metastases from a breast carcinoma
primary. The differential diagnosis includes lymphoma.
Diagnosis
Differential diagnosis
(Mnemonic MetsLP HIM):
Lymphoma.
Pagets disease.
Haemangioma.
Infection.
Mastocytosis.
Discussion
The ivory vertebra sign refers to an increase in opacity of a
vertebral body that retains its size and contours.
In adults:
Osteoblastic metastases elicit a sclerotic response that
results in patchy replacement of the vertebral body
spongiosa with dense new bone that may be confluent
(137b, 137c). Sclerotic metastases from prostate
carcinoma in men and breast carcinoma in women are
the most common primaries. Occasionally
osteosarcoma and carcinoid are responsible.
Lymphomatous deposits can also elicit a marked
osteoblastic response resulting in diffuse sclerosis.
When considering lymphoma as a cause, Hodgkins
137b
137c
137d
244
Answer 137
Musculoskeletal Imaging
In children:
The ivory vertebra sign is less common in children and
frequently the result of lymphoma.
Less commonly, osteoblastoma, neuroblastoma,
osteosarcoma or medulloblastoma deposits can cause
the appearance.
Practical tips
Increased vertical trabeculation and expansion suggest
Pagets or haemangioma. The latter affects a younger
age group, whereas the former is seen in the elderly
and may be polyostotic.
A paraspinal mass may be seen with lymphoma due to
adenopathy, which may also cause anterior scalloping
of the vertebral bodies.
With mastocytosis, look for involvement of several
vertebrae and background small bowel
CASE 138
Case 138
Further management
The underlying cause can be determined from the age of
the patient, ancillary signs on the radiograph (as described
above) and the history and examination. An isotope bone
scan may be required to locate further deposits in a patient
with metastases.
Further reading
Graham TS (2005). The ivory vertebra sign. Radio lo gy
235: 614615.
138a
History
A 67-year-old male presented with
a swollen foot.
245
Answer 138
Musculoskeletal Imaging
ANSWER 138
Observations (138a)
Differential diagnosis
Practical tips
Diagnosis
Further management
Treatment is supportive. Amputation may be necessary in
severe progression.
Spine:
Trauma.
Tabes dorsalis.
Hip and knee:
Tabes dorsalis.
Steroids.
Ankle and foot:
Diabetes mellitus.
Alcoholism.
Myelomeningocele.
Congenital insensitivity to pain.
Discussion
Neuropathic arthropathy is a traumatic arthritis associated
with loss of sensation and proprioception of an affected
limb. When encountered clinically it is also known as a
Charcot joint. The decreased pain sensation produces
repetitive trauma leading to eventual destruction of the
joint. There is often no history of trauma and the patient
may present with a swollen warm joint with normal
inflammatory markers. A third have pain at presentation
although there is usually a decreased response to deep pain
and proprioception at this stage. Because the patient is still
using the limb there is no juxta-articular osteoporosis, in
fact the bones are sclerotic. The exception to this rule is in
patients with superadded infection, which is not
uncommon in diabetics. Repetitive trauma leads to
destruction, dislocation and deformity with multiple loose
bodies within the joint. The likely underlying pathology
depends upon the site of the joint and the age of the
patient. When considering the ankle and foot, the most
common causes in adults are diabetes mellitus and
alcoholism, whereas in children the most common causes
are myelomeningocele and congenital insensitivity to pain.
Examples are shown of a Charcot joint secondary to
diabetes mellitus (138b) and a Charcot elbow in a patient
with syringomyelia (138c).
246
138b
Answer 138
Musculoskeletal Imaging
Case 139
138c
CASE 139
139a
History
A 30-year-old male patient
presented with right hip pain and
limitation of movement.
247
Answer 139
Musculoskeletal Imaging
ANSWER 139
Observations (139a)
Irregularity, sclerosis and loss of height of the right femoral
head are seen on the pelvic radiograph. There is no
significant abnormality of the acetabulum and the left hip is
unremarkable. The findings are consistent with avascular
necrosis of the right hip. Bilateral sacroiliac joint fusion is
also present, though more prominent on the right side.
This suggests a background seronegative arthropathy. It is
therefore likely that the avascular necrosis is drug induced
by treatment for the seronegative arthropathy, or perhaps
associated inflammatory bowel disease. No bowel
abnormality is seen on this plain film to confirm the latter
hypothesis.
139b
Diagnosis
Avascular necrosis (AVN) in a patient on steroids for
seronegative arthropathy.
Differential diagnosis
For causes of avascular necrosis (mnemonic DRIED
HIP):
Diabetes and other metabolic conditions, e.g.
hyperlipidaemia, gout, pancreatitis.
Radiotherapy.
Inflammatory disorders, e.g. rheumatoid, SLE,
scleroderma.
Endocrine disorders, e.g. Cushings.
Drugs, e.g. steroids, anti-inflammatory and
immunosuppressive drugs, alcohol.
Haematological disorders, e.g. sickle cell, haemophilia,
polycythaemia, Gauchers.
Infection and injury, e.g. fractures, burns and fat
embolism.
Perthes disease (idiopathic AVN in children).
139c
Discussion
Avascular necrosis is a consequence of interrupted blood
supply to bone with death of cellular elements. The many
causes are listed in the differential diagnosis and follow the
mnemonic DRIED HIP. The femoral head is the most
common site affected. Other common locations include the
humeral head and femoral condyles. The earliest
radiological sign is subtle relative sclerosis secondary to
resorption of surrounding bone. A radiolucent crescent
parallel to the articular surface may appear. Flattening,
fragmentation and sclerosis then ensue. Subchondral cysts
and collapse lead to early osteoarthritis of the affected joint.
An AP of the pelvis (139b) shows the subtle crescent sign
in the left hip of a child with early avascular necrosis. This
is more clearly seen on the frog lateral view of the same
patient (139c).
248
Answer 139
Musculoskeletal Imaging
Practical tips
The list of potential causes for AVN is long and, of course,
it may just be idiopathic Perthes disease in children. The
following radiological features are worth checking for in
the search for a cause, but clinical history may be required
thereafter. For example, the child with AVN shown in
Figure 139b had leukaemia, and steroid treatment was the
cause.
Check for:
Signs of sickle cell anaemia, e.g. vertebral endplate
infarctions producing H-shaped vertebrae, altered
bony trabecular pattern, gallstones and splenic
calcification.
Associations with steroid therapy, e.g. thumb-printing
in colon, presence of a stoma or sacroiliitis.
CASE 140
Case 140
Further management
The underlying cause should be sought and treated. Many
patients will develop debilitating secondary arthritis and
go on to require replacement of the affected joint.
140a
History
A 64-year-old patient presented
with abdominal pain.
249
Answer 140
Musculoskeletal Imaging
ANSWER 140
Observations (140a)
Discussion
Diagnosis
Practical tips
Myelofibrosis.
Differential diagnosis
Of diffuse bony sclerosis and splenomegaly:
Lymphoma.
Mastocytosis.
Of generalized osteosclerosis in adults:
Sclerotic metastases (especially breast or prostate
carcinoma).
Lymphoma.
Myelofibrosis.
Pagets disease (140b).
Renal osteodystrophy.
Sickle cell disease.
Mastocytosis.
Osteopetrosis.
Pyknodysostosis.
Fluorosis.
Osteopetrosis and pyknodysostosis have onset in the
paediatric age group.
140b
140c
250
140d
Answer 140
Musculoskeletal Imaging
Case 141
Further management
CASE 141
140e
141a
History
A
34-year-old
male
presented with right hip
pain.
251
Answer 141
Musculoskeletal Imaging
ANSWER 141
Observations (141a)
There is a large, expansile, mixed lytic/sclerotic destructive
lesion involving the right anterior hemipelvis. There is
marked cortical destruction with a soft tissue component.
The lesion has a wide zone of transition. This is an
aggressive lesion and the most likely diagnosis in a patient
of this age is a primary malignancy such as lymphoma or
chondrosarcoma. Metastasis should also be considered.
Diagnosis
Practical tips
It can often be difficult to differentiate an enchondroma
from an intramedullary chondrosarcoma, however the
latter is more likely to present with pain and unlike
enchondroma will often demonstrate periosteal reaction
and cortical breakthrough.
Chondrosarcoma.
Further management
Differential diagnosis
Lymphoma.
Metastasis.
Discussion
Chondrosarcoma is the third most common primary bone
malignancy with multiple myeloma being the most
common and osteosarcoma following second. Chondrosarcoma can be primary, or secondary following malignant
transformation in a pre-existing skeletal lesion such as an
osteochondroma, enchondroma or a parosteal chondroma.
Chondrosarcoma most commonly presents in the 4th or
5th decade of life with a male predilection of 2:1.
Radiographs typically reveal a mixed lytic and sclerotic
appearance. The sclerotic areas represent chondroid matrix
mineralization and are seen in 6078% of lesions. The
characteristic appearance of mineralized chondroid matrix
is a ring and arc pattern of calcification that can coalesce to
form snowflake-type calcification. This characteristic
chondroid calcification usually allows confident radiological
diagnosis of a cartilaginous lesion.
Radiological signs:
Mixed lytic/sclerotic lesion.
Wide zone of transition.
Ring and arc and snowflake calcification.
Cortical destruction.
Soft tissue mass.
Chondrosarcomas are also characterized as central or
peripheral. Central chondrosarcomas make up the majority
and are intramedullary in origin, although they may erode
through the cortex into the soft tissues. Central
chondrosarcomas usually arise in the pelvis or femur and
are often expansile with the characteristic calcification
described. Endosteal scalloping is often seen and can help
differentiate low-grade chondrosarcomas from enchondromas. Clinical symptoms are nonspecific, with pain being
the most frequent symptom. Peripheral chondrosarcoma is
also termed exostotic chondrosarcoma and refers to
malignant degeneration in an exostosis (i.e. is a secondary
chondrosarcoma). An example is shown in Figure 141b
note the flocculent calcification of the chondrosarcoma,
which had arisen from the exostosis at the lateral femoral
condyle. This should always be suspected when there is
growth of an exostosis after skeletal maturity or if an
exostosis becomes painful. The cartilage cap of a suspicious
exostosis can be measured on MRI, and if the thickness is
252
Further reading
Murphey M, Walker E, Wilson A, et al. (2003). Imaging
of primary chondrosarcoma: radiologic-pathologic
correlation. Radio Graphics 23: 12451278.
141b
Musculoskeletal Imaging
Case 142
CASE 142
History
A 45-year-old male presented with
severe back pain for several weeks.
142a
142b
253
Answer 142
Musculoskeletal Imaging
ANSWER 142
Observations (142a, 142b)
AP and lateral images (142a) of the thoracolumbar spine
show marked deformity at the T12/L1 level with erosive
destruction of the opposing vertebral endplates. There is
anterior slip at this level with anterior angulation (gibbus
deformity). Appearances are in keeping with a discitis.
Axial and coronal T2 weighted MR images (142b)
demonstrate high signal in the T12/L1 intervertebral disc.
Signal change extends throughout the adjacent vertebrae,
and there is endplate destruction and partial vertebral
collapse at T12. T11 vertebra has increased marrow signal
suggesting it is also involved. The axial image demonstrates
high-signal fluid collections in both psoas muscles
consistent with bilateral psoas abscesses.
Diagnosis
Tuberculous spondylitis (Potts disease) with associated
psoas abscess.
Discussion
The spine is the most common bony location to be
involved in TB. Presentation is often late since initial
symptoms are of vague back pain and stiffness. The most
common location is the upper lumbar/lower thoracic
region, particularly around L1 level. The anterior aspect of
the vertebral body is most typically affected. The disk space
then becomes involved via extension along the anterior or
posterior longitudinal ligament or directly through the
endplate.
Practical tips
Discitis will cause bony abnormality of the superior
and inferior endplates of the adjacent vertebral bodies,
i.e. abnormality will be centred at the level of the disc.
The vertebral disc space is maintained longer in TB
spondylitis than in pyogenic discitis.
Look at the paraspinal regions to look for spread of
infection. Infection can present as leg pain/swelling
due to tracking of collections down the iliopsoas
muscle.
Look at, and around the spinal cord for extradural
collections and spinal involvement.
Further management
Treatment is with antituberculous medication. Drainage
of associated psoas or epidural abscesses may be required.
142b
254
Musculoskeletal Imaging
CASE 143
143a
History
A 40-year-old male patient
presented with painful fingers.
CASE 144
144a
History
A young male presented with
pain in left hand following a
fight.
(see page 258 fo r case answer)
255
Answer 143
Musculoskeletal Imaging
ANSWER 143
Observations (143a)
Practical tips
Diagnosis
Psoriatic arthropathy.
Differential diagnosis
Ankylosing spondylitis.
Rheumatoid arthritis (RA).
Discussion
This is a seronegative arthropathy affecting synovium and
ligamentous attachments, and affects fewer than 5% of
psoriasis patients. In approximately 15%, the arthropathy
can predate development of skin changes by several years.
The pattern of disease is variable, though the case illustrated
is classical, i.e. asymmetric erosive oligoarthritis affecting
the distal joints of hands and feet. New bone formation is
characteristic, and may result in ankylosis of interphalangeal
joints, as in this case. Resorption of the distal phalangeal
tufts may be seen with accompanying nail changes.
Spondyloarthropathy is another pattern of disease, often
with sacroiliitis and paravertebral ossifications. Other disease
patterns include symmetrical polyarthritis mimicking
rheumatoid, monoarthritis and arthritis mutilans, a grossly
destructive pattern that may progress to form opera glass
hand.
256
RA:
Bilateral symmetrical ero sive arthropathy.
Metacarpophalangeal and proximal
interphalangeal joints affected, i.e. pro ximal
small jo ints o f digits.
Marginal erosions.
Subluxation with ulnar deviation of digits.
Decreased bo ne density.
Ankylosis.
Figure 143b is a radiograph of both hands in a
patient with rheumatoid arthritis demonstrating
bilateral symmetrical erosive destruction of the
metacarpophalangeal joints. There is also
generalized decreased bone density and
arthropathy at the carpal joints and radiocarpal
joints. Figure 143c shows similar changes in the
feet of a rheumatoid patient with marginal
erosions and symmetrical subluxation at the
metatarsophalangeal joints bilaterally.
143b
143c
Answer 143
Musculoskeletal Imaging
Gouty arthropathy:
Asymmetrical erosive arthropathy.
Erosions are juxta-articular with o verhanging
edges.
Preserved bone density and joint space.
Bony proliferation/periosteal reaction.
Go uty to phi causing soft tissue masses in 50%.
Figures 143d and 143e are radiographs of gout
demonstrating an asymmetrical erosive
arthropathy with punched out erosions. These
erosions have overhanging edges, which are best
seen at the proximal interphalangeal joints of the
index fingers bilaterally and the
metacarpophalangeal joint of the right thumb.
Further large punched out juxta-articular
erosions with associated tophi are seen around
the base of the right big toe in particular. Note
the preservation of bone density.
143d
143e
Further management
Given the inflammatory nature of the disease, treatment
consists of anti-inflammatory and immunosuppressive
drugs as for other inflammatory arthropathies.
257
Answer 144
Musculoskeletal Imaging
ANSWER 144
Observations (144a)
Practical tips
Further management
Diagnosis
Enchondroma.
Differential diagnosis
For lytic lesion in the digits (mnemonic SEGA GAME
F):
Simple bone cyst rare in the hand.
Enchondroma is by far the most likely lesion with this
appearance at this site.
Giant cell tumour of tendon sheath.
Aneurysmal bone cyst rare in the hand.
Glomus tumour painful.
Abscess/osteomyelitis.
Metastases and myeloma.
Epidermal inclusion cyst (intraosseous) distal
phalanx; history of trauma, erythema and swelling may
be present.
Fibrous dysplasia rare in the hand.
Discussion
Enchondroma is a common benign cartilaginous tumour
most commonly seen in the tubular bones (50% in hands
and feet) of patients under the age of 30 years.
The cardinal radiological features are listed below:
Central lesion within the medullary canal.
Lucent expansion of bone.
Narrow zone of transition.
Thinning of the cortex but no cortical breakthrough.
No periosteal reaction unless pathological fracture.
Stippled calcification may be present.
Cortical endosteal scalloping.
Affects small tubular bones.
Olliers disease occurs when multiple enchondromas are
present (144b). The enchondromas are most commonly
seen in the femur, tibia and hands in an asymmetrical
distribution. In the long bones, presentation is with
asymmetric limb shortening due to impairment of epiphyseal fusion. The lesions do not increase in size after
cessation of normal growth. Malignant transformation to
chondrosarcoma can occur in up to 25% of patients with
Olliers disease by the age of 40. Malignant change is more
common in central lesions and should be suspected when
there is abnormal continued growth with pain and swelling
and/or imaging findings of growth in a previously stable
lesion, bony erosion and new or increasing calcification.
Maffuccis syndrome describes multiple enchondromas
with multiple soft tissue haemangiomas, which present on
imaging as multiple phleboliths in the soft tissues. It
presents later, usually after puberty, and has a much higher
incidence of malignant transformation.
258
144b
Musculoskeletal Imaging
CASE 145
145
History
Follow-up hand x-ray in an
older child.
CASE 146
146
History
Adult patient presented with heel pain.
259
Musculoskeletal Imaging
ANSWER 145
Observations (145)
Practical tips
Diagnosis
Osteopetrosis causing a bone within bone appearance.
Differential diagnosis
Of bone within bone appearance (mnemonic SHARPS
POOL):
Sickle cell disease.
Hypervitaminosis D.
Acromegaly.
Rickets.
Pagets disease.
Scurvy.
Post-radiation therapy/thorotrast/heavy metal
poisoning.
Osteopetrosis and oxalosis.
Osteomyelitis.
Leukaemia.
Discussion
Bone within bone describes the radiological appearance
where one bone appears to arise within another. It can be
seen as part of normal development, especially in the spine.
Growth arrest may also cause the appearance but there are
several pathological causes as listed. The diffuse
osteosclerosis and age of the patient in this case (145) point
to the correct diagnosis.
Further management
The only treatment available for osteopetrosis is bone
marrow transplantation. Patients are more prone to
fractures than the normal population.
Further reading
Williams H, Davies A, Chapman S (2004). Bone within
a bone. Clinical Radio lo gy 59: 132144.
ANSWER 146
Observations (146)
Within the body of the calcaneus there is a well-defined
lucent lesion with a narrow zone of transition. The lesion
has a very thin sclerotic border and centrally within the
lesion is a clump of calcification. There is no periosteal
reaction or overlying soft tissue mass. The lesion has a
nonaggressive appearance and the findings are typical of
an intraosseous lipoma.
Diagnosis
Intraosseous lipoma.
Differential diagnosis
Discussion
The calcaneus is the most common location for an
intraosseous lipoma. Other sites of involvement include
the proximal femur, tibia, humerus, pelvis, mandible and
vertebrae. When involving tubular bones, it is usually
located at the metaphysis. Patients of any age may develop
260
Practical tips
Intraosseous lipoma (lipoma of bone) can occur at
any age.
A central clump of calcification is virtually diagnostic.
Further management
This is a benign bony lesion and no further management
is necessary.
Musculoskeletal Imaging
CASE 147
Case 147
147a
History
A 30-year-old female presented after a
fall onto outstretched hand.
261
Answer 147
Musculoskeletal Imaging
ANSWER 147
Observations (147a)
There is shortening of the 4th metacarpal. No acute bony
injury is seen. The findings are most likely to be idiopathic
or due to previous trauma. However, less common causes
such as Turners syndrome, pseudohypoparathyroidism and
pseudopseudohypoparathyroidism should also be
considered.
Diagnosis
Idiopathic shortening of the 4th metacarpal.
Differential diagnosis
Practical tips
Discussion
Shortening of the 4th metacarpal can result from previous
trauma, particularly that involving the growth plate during
childhood. Pseudohypoparathyroidism is a congenital Xlinked dominant abnormality of renal and skeletal resistance
to parathyroid hormone due to end-organ resistance and
defective hormone. Patients therefore have the same
characteristics as those with hypoparathyroidism but also
short obese stature, round face, mental retardation,
abnormal dentition and hypocalcaemia. Shortening of the
3rd metatarsal occurs along with shortening of the 4th and
5th metacarpals and is seen in up to 75% (147b).
147b
262
Further management
There is no further treatment. This finding is most
commonly idiopathic or related to previous trauma and is
often incidental.
Answer 147
Musculoskeletal Imaging
Case 148
147c
CASE 148
148a
History
A 14-year-old boy presented with thigh
pain, which was worse during the night.
263
Answer 148
Musculoskeletal Imaging
ANSWER 148
Observations (148a)
There is an area of dense sclerosis affecting the shaft of the
femur with associated cortical thickening. Within this is an
area of central lucency. This likely represents a nidus and
the features are therefore consistent with an osteoid
osteoma. Depending on other clinical features, infection
might be considered as a differential diagnosis.
Diagnosis
Osteoid osteoma.
Differential diagnosis
Infection.
Eosinophilic granuloma.
Discussion
Osteoid osteoma is a relatively common, benign skeletal
neoplasm composed of woven and osteoid bone, with loose
intervening fibrovascular tissue. The lesion itself rarely
exceeds 1.5 cm in maximum dimension and there are three
main types: cortical, cancellous and subperiosteal.
Cortical lesions are the most common and have
characteristic findings. Radiographs show dense reactive
sclerosis that affects the shaft of a long bone, especially the
tibia and femur. The lesion itself, however, is a radiolucent
area within this area of osteosclerosis known as the nidus.
This is more clearly seen on the CT images of the same
patient (148b).
Cancellous osteoid osteomas have a site predilection for
the femoral neck, posterior elements of the spine and the
small bones of the hands and feet. By comparison, the
sclerosis associated with a cancellous lesion is usually mild
148b
264
Answer 148
Musculoskeletal Imaging
Case 149
Practical tips
Further reading
Further management
Treatment consists of complete removal of the nidus.
Conventional treatment is surgical, however many cases are
now treated radiologically with CT-guided laser
photocoagulation. Greater than 90% success rates are
reported with this technique.
CASE 149
149a
History
A young adult presented after
falling onto left arm.
265
Answer 149
Musculoskeletal Imaging
ANSWER 149
Observations (149a)
There is an extensive, expansile lucent lesion involving the
length of the left humerus, predominantly the metaphyses
and diaphysis. Remodelling of the bone is evident and the
lesion has ground glass density in some places. There is,
however, no cortical break or periosteal reaction and the
lesion has nonaggressive features. The most likely diagnosis
is fibrous dysplasia.
Diagnosis
Fibrous dysplasia.
Discussion
Fibrous dysplasia is a benign fibro-osseous developmental
anomaly of bone whereby the medullary cavity becomes
replaced by an immature matrix of collagen and woven
bone. Males and females are equally affected and 75% of
patients develop the disease before the age of 30 years. The
monostotic form, which most commonly affects the ribs,
proximal femur and craniofacial bones, accounts for 80%
of cases.
The polyostotic form (i.e. involving more than one site)
is seen in the remaining 20% and predominantly affects the
femur, tibia, pelvis and facial bones. A subtype of the
polyostotic form is McCuneAlbright syndrome, where
polyostotic unilateral fibrous dysplasia is associated with
caf-au-lait spots and precocious puberty in young girls.
Radiologically, a ground glass density lesion in the
medullary cavity is the characteristic feature. The metaphysis
149b
266
149c
Answer 149
Musculoskeletal Imaging
Metadiaphyseal location.
Remodelling/alteration in bone architecture.
Endosteal scalloping.
Shepherds crook deformity when affecting proximal
femur.
Limb length discrepancy.
Pathological fracture.
No cortical destruction.
Nonaggressive features.
Practical tips
149d Radiographs
of the leg in a child
demonstrate a
lucent/ground
glass lesion in the
diaphysis, which
has nonaggressive
features and is
typical of
osteofibrous
dysplasia.
Case 150
149d
Further management
There is no specific treatment for fibrous dysplasia.
Pathological fractures often occur and may necessitate
surgical fixation.
CASE 150
History
A 44-year-old female presented with
wrist pain.
150a
150b
267
Answer 150
Musculoskeletal Imaging
ANSWER 150
Observations (150a, 150b)
Axial images of the wrist with T1 weighting (150a) and T2
fat saturation (150b) are shown. Inflamed tendon sheaths
are of high signal on T2 fat saturated images and low signal
on T1 weighted images. In addition, there is palmar
bowing of the flexor retinaculum. The median nerve is of
increased signal on the T2 weighted image. This
combination of features is consistent with a diagnosis of
carpal tunnel syndrome.
Diagnosis
Carpal tunnel syndrome.
Discussion
Carpal tunnel syndrome is a disease that arises due to
chronic pressure on the median nerve as it passes within the
carpal tunnel, usually associated with repetitive wrist
movements. It is more commonly seen in females with a
ratio of 4:1 and is bilateral in 50% of cases. Usually
diagnosis is made by clinicians with positive findings on
clinical examination, electromyelography and nerve
conduction studies. Radiological examinations have a role
in the few cases where these investigations are inconclusive.
Ultrasound is usually the first examination undertaken
although MRI has been shown to be more specific and
sensitive. US findings are of:
Median nerve swelling in the proximal tunnel/level of
the distal radius.
Nerve flattening in the distal tunnel.
Bowing of the flexor retinaculum.
Practical tips
Assessment of nerve swelling can be made by comparing
the size of the median nerve at the level of the distal
radius and at the hamate.
Further management
Methods to decrease oedema and swelling within the
carpal tunnel such as treatment of hypothyroidism or
restriction of fluid intake can help relieve symptoms.
However the gold standard treatment for carpal tunnel
syndrome is surgical decompression.
150b
268
Musculoskeletal Imaging
Case 151
CASE 151
History
An adult female patient with back pain.
151a
151b
269
Answer 151
Musculoskeletal Imaging
ANSWER 151
Observations (151a, 151b)
AP and lateral radiographs of the lumbar spine show
posterior vertebral scalloping of the lower lumbar vertebrae
with a narrowed anteroposterior canal diameter. The AP
film (151a) shows that the interpedicular distance is
abnormally narrowed at L5 level and there is squaring of
the iliac wings. The features are consistent with
achondroplasia.
Diagnosis
Achondroplasia.
Differential diagnosis
Of posterior vertebral scalloping:
Pressure effect tumours in spinal canal,
syringomyelia and communicating hydrocephalus.
Dural ectasia. This occurs in neurofibromatosis,
Marfans and EhlersDanlos.
Acromegaly.
Achondroplasia.
Congenital disorders such as mucopolysaccharidoses,
e.g. Morquios syndrome.
Discussion
270
151c
151d
Answer 151
Musculoskeletal Imaging
Practical tips
Achondroplasia is an Aunt Minnie familiarity with
the features makes it a straightforward viva case.
When the sacrum is not seen, possibilities include
agenesis, destruction and a horizontal position as in
achondroplasia check for other supporting evidence
of the latter, such as narrowing of the interpedicular
distance in the lower lumbar spine.
Posterior vertebral scalloping on plain film check for:
Narrowing of the interpedicular distance caudally in
achondroplasia.
Cutaneous nodules of neurofibromatosis.
Rectangular vertebrae with chondrocalcinosis in
acromegaly.
Case 152
151e Shortening of
both legs is seen in this
achondroplastic with
flaring of the
metaphyses producing
a trumpet appearance.
151e
151f
Further management
There is no cure for the condition but affected individuals
can normally expect a long life.
Further reading
Cheema J, Grissom L, Harcke H (2003). Radiographic
characteristics of lower-extremity bowing in children.
Radio Graphics 23: 871880.
CASE 152
152a
History
A middle aged female
presented with dysphagia.
271
Answer 152
Musculoskeletal Imaging
ANSWER 152
Observations (152a)
Practical tips
Diagnosis
Scleroderma.
Differential diagnosis
Of acro-osteolysis (mnemonic SHARTEN):
Scleroderma.
Hyperparathyroidism.
Arthropathy psoriasis, erosive osteoarthritis,
rheumatoid, etc.
Raynauds.
Trauma and thermal injury.
Epidermolysis bullosa.
Neuropathy, e.g. syringomyelia and diabetes.
Of fingertip calcification:
Scleroderma.
Raynauds.
Hyperparathyroidism.
Dermatomyositis.
Discussion
Acro-osteolysis is the term used to describe resorption or
destruction of the distal phalangeal tufts. There are many
causes but only the more relevant and common ones are
listed. The three main patterns of involvement are: distal
tuft, midportion and periarticular (i.e. at the base).
Periosteal reaction is not usually seen at the site of
resorption.
Further management
There is no cure for scleroderma. Treatment is supportive.
152b
272
Musculoskeletal Imaging
CASE 153
CASE 154
History
History
153
154
273
Musculoskeletal Imaging
ANSWER 153
Observations (153)
There is relative shortening and ulnar curve of the distal
radius with wedging of the carpus between the distal radius
and ulna. The features are consistent with Madelung
deformity. There are no exostoses to indicate diaphyseal
aclasis, and a more specific cause cannot be established
from this film.
Diagnosis
Madelung deformity.
Differential diagnosis
Of causes of Madelung deformity (mnemonic TILDti):
Turners syndrome.
Idiopathic.
LeriWeil disease (dyschondrosteosis).
Diaphyseal aclasis.
Trauma and Infection can lead to pseudo-Madelung
deformity.
Discussion
Madelung deformity comprises a short distal radius which
has abnormal dorsal and ulnar curvature resulting in ulnar
tilt of the distal radial articular surface. The distal ulnar is
also subluxed dorsally, and the triangular-shaped carpus is
wedged into the reduced carpal angle created at the wrist.
There are several conditions associated with Madelung
Practical tips
Look for metaphyseal exostoses pointing away from
the joints indicating diaphyseal aclasis.
Look for shortening of the 4th metacarpal, which is
associated with Turners syndrome.
Further management
There is no specific treatment for this condition.
ANSWER 154
Observations (154)
Discussion
Diagnosis
Eosinophilic granuloma causing vertebra plana.
Differential diagnosis
For vertebra plana:
Idiopathic.
Infection.
Neoplastic (metastasis, leukaemia).
Trauma.
Steroids.
Haemangioma.
For platyspondyly:
Thanatophoric dwarfism.
Osteogenesis imperfecta.
Morquios disease.
Spondyloepiphyseal dysplasia congenital.
Kniest syndrome.
274
Answer 154
Musculoskeletal Imaging
Practical tips
The vertebral body affected has a uniformly flat coin
on edge appearance.
Intervertebral discs are typically spared with normal
disc spaces.
The posterior elements are spared.
Marked generalized osteopenia suggests osteogenesis
imperfecta.
Malignant causes may affect more than one vertebral
body.
Case 155
Further management
The underlying cause should be determined if possible.
Eosinophilic granuloma is the most common cause in
children and usually resolves spontaneously with age.
CASE 155
History
A young adult presented with
abdominal pains.
155a
275
Answer 155
Musculoskeletal Imaging
ANSWER 155
Observations (155a)
Practical tips
Diagnosis
Sickle cell disease.
Discussion
Sickle cell disease is an inherited disorder mostly seen in
Afro-Caribbeans. The sickling of the red blood cells leads to
increased blood viscosity, occlusion of small vessels and
bone infarction leading to necrosis. Chronic haemolytic
anaemia also ensues. Marrow hyperplasia leads to
coarsening of the trabeculae and may cause diffuse
osteosclerosis. A CXR in a 17-year-old female with sickle
cell disease is shown (155b). This demonstrates diffuse
osteosclerosis with H-shaped thoracic vertebrae (due to
endplate infarctions) and cardiomegaly (secondary to
chronic anaemia).
276
Chest radiograph:
H-shaped vertebrae due to endplate infarctions.
Avascular necrosis of the humeral heads.
Cardiomegaly (due to chronic anaemia).
Skull radiograph:
Hair on end appearance of skull vault due to
marrow hyperplasia.
Widening of diploic space.
Further management
Treatment is generally supportive with multiple
transfusions being necessary. There is a high incidence of
infection of bone and lung. Skeletal pain can occur not
only from osteomyelitis but also from bone marrow
infarction.
155b
155c
Musculoskeletal Imaging
Case 156
CASE 156
History
An 80-year-old woman presented with
left arm and right leg pain.
156
277
Answer 156
Musculoskeletal Imaging
ANSWER 156
Observations (156)
A full body bone scan is presented. There is widespread,
diffuse increased skeletal uptake with more focal areas of
increased uptake located in the skull, spine, ribs, pelvis and
limbs. No renal uptake of isotope is seen, however there is
some uptake in the bladder. The findings are therefore
consistent with a superscan and the most likely cause is
widespread metastases.
Diagnosis
Superscan due to widespread metastases.
Differential diagnosis
Of causes of a superscan:
Diffuse skeletal metastases.
Renal osteodystrophy.
Osteomalacia.
Hyperparathyroidism.
Hyperthyroidism.
Myelofibrosis.
Leukaemia.
Aplastic anaemia.
Widespread Pagets disease.
Practical tips
Discussion
Diffusely increased activity in the bones on an isotope bone
scan can result in an absent kidney sign where there is little
or no activity in the kidneys but good visualization of the
urinary bladder. This is termed a superscan. The key
finding is the absence of activity in the kidneys, which can
be easily missed when the diffuse increase in skeletal activity
is overlooked. In fact many such scans were reported as
normal in the past until the importance of absent renal
activity secondary to diffuse skeletal uptake was realized.
156
278
156 No renal
uptake.
Further management
When a superscan is seen, the most important factor is to
determine whether the cause is due to metabolic or
malignant disease. This may be evident from the history
and clinical examination.
Musculoskeletal Imaging
CASE 157
Case 157
157a
History
An elderly patient presented with leg
pains.
279
Answer 157
Musculoskeletal Imaging
ANSWER 157
Observations (157a)
Practical tips
Differential diagnosis
Further management
Diagnosis
Discussion
Focal periosteal reaction demands careful assessment for an
underlying bone lesion including tumour, infection,
fracture, etc. However, diffuse reaction that is bilateral and
may well affect multiple bones is a different scenario
requiring this brief differential diagnosis:
HPOA is the most likely cause for such an appearance
in adults. The condition presents with painful swelling
and clubbing may occur. The periosteal reaction is of
variable thickness and typically affects the lower half of
the arm and leg. Soft tissue swelling and periarticular
osteoporosis may be appreciable radiologically. A chest
radiograph should be requested to exclude a lung
tumour. Other causes of hypertrophic
osteoarthropathy include fibrotic lung disease,
suppurative lung disease, liver cirrhosis and
inflammatory bowel disease.
Vascular insufficiency (arterial or venous) is almost
always seen in the lower limbs.
Thyroid acropachy periosteal reaction typically
affects the radial side of the thumb and index fingers.
Clubbing of the fingers may be present. An example is
shown (157b), although the thumb and index fingers
are affected, periosteal reaction is also seen along most
of the phalanges and the 5th metacarpal.
Pachydermoperiostosis is an autosomal dominant
condition, typically seen in young black males. It is
relatively pain free and self-limiting but causes skin
thickening and clubbing. Enlarged paranasal sinuses
are also seen. Periosteal reaction most commonly
affects the lower half of the arm and leg, though hands
can also be affected. Periosteal reaction looks very
similar to HPOA but begins around ligament and
tendon insertions, i.e. close to the epiphysis.
Fluorosis ligamentous calcification present.
280
157b
Musculoskeletal Imaging
CASE 158
Case 158
158
History
A 14-year-old male presented with
arm pain.
281
Answer 158
Musculoskeletal Imaging
ANSWER 158
Observations (158)
Within the midshaft of the diaphysis of the humerus there
is a relatively well defined lytic lesion that has a narrow zone
of transition. There is endosteal scalloping and smooth
lamellated periosteal reaction. The lesion has nonaggressive
features and in this age group eosinophilic granuloma or
infection is the most likely diagnosis.
Diagnosis
Eosinophilic granuloma.
Differential diagnosis
Osteomyelitis.
Fibrous dysplasia.
Leukaemia.
Lymphoma.
Practical tips
Discussion
Langerhans cell histiocytosis is a spectrum of disease
characterized by idiopathic proliferation of histiocytes
producing focal or systemic manifestations. Eosinophilic
granuloma is the term used to describe the disease when
limited to bone and is mostly seen in patients aged between
5 and 30 years. The clinical and radiological features may
mimic infection as well as other benign and malignant
diseases. The cause and pathogenesis of the condition are
unknown. Clinical manifestations relate to the affected
bone with local pain, tenderness and masses commonly
observed. Patients may have low-grade fever or elevated
inflammatory markers, which confuses the clinical picture
with infection. The disease may occur in any bone,
although there is a predilection for the flat bones with more
than half occurring in the skull, mandible, ribs and pelvis.
Lesions are solitary in 5075% of cases. Approximately onethird of lesions occur in the long bones, most commonly
the femur followed by the humerus and tibia. Most lesions
occur in the diaphysis, and in general the growth plate acts
as a barrier to extension.
282
Further management
The prognosis of eosinophilic granuloma is excellent with
spontaneous resolution of bony lesions occurring in 618
months.
Further reading
Levine S, Lambiase R, Petchprapa C (2003). Cortical
lesions of the tibia: characteristic appearances at
conventional radiography. Radio Graphics 23:
157177.
Stull M, Kransdorf M, Devaney K (1992). Langerhans
cell histiocytosis of bone. Radio Graphics 12(4):
801823.
Musculoskeletal Imaging
Case 159
CASE 159
History
A 24-year-old male presents with knee instability
following a football injury 2 months previously.
159a
283
Answer 159
Musculoskeletal Imaging
ANSWER 159
Observations (159a)
Sagittal T2 weighted images of the knee demonstrate a
rupture of the anterior cruciate ligament, no intact fibres
being demonstrated. In keeping with this, there is mild
anterior tibial translocation. The posterior cruciate ligament
(PCL) is intact.
There is loss of the normal bow tie appearance of the
lateral meniscus with non-visualization of the body and
much of the posterior horn. Furthermore, abnormal low
signal tissue is present in the intercondylar region just lateral
to the PCL. These findings are indicative of a bucket
handle tear of the lateral meniscus with a fragment of
meniscus displaced medially. A joint effusion is also present.
Diagnosis
Anterior cruciate ligament (ACL) rupture with bucket
handle tear of the lateral meniscus.
Differential diagnosis
None.
Discussion
The ACL is best evaluated on T1 weighted images and
fibres should run parallel to the roof of the intercondylar
notch (159b). ACL tears most commonly leave no normal
residual fibres visible on MRI. Sometimes, residual fibres
of the ACL are seen, but following a more horizontal
course than normal.
Sagittal images of normal menisci show a bow tie
appearance on at least two contiguous slices (159c). This
is because the normal meniscus is approximately 9 mm in
width and the sagittal images are 34 mm in thickness.
Thus, at least two sagittal slices should pass through a
contiguous section of meniscus.
Bucket handle tears constitute about 10% of meniscal
tears. The vertical tear through the inner edge produces a
159b
284
Further management
A complete ACL tear causes instability that is treated
by surgical repair with a prosthetic or tendon graft.
Meniscal tears often require arthroscopic
debridement.
159c
159d
Musculoskeletal Imaging
CASE 160
Case 160
160a
History
A female patient presented with joint
pains.
285
Answer 160
Musculoskeletal Imaging
ANSWER 160
Observations (160a)
There is subperiosteal resorption of the radial aspect of the
middle phalanges of the index and middle fingers. No
evidence of marginal erosions or brown tumours is seen
though the trabecular pattern is coarsened. The findings
are consistent with hyperparathyroidism.
Diagnosis
Hyperparathyroidism.
Discussion
The uncontrolled production of parathyroid hormone in
hyperparathyroidism is primary, secondary or tertiary.
Primary hyperparathyroidism is caused by a parathyroid
adenoma. The raised parathyroid hormone levels lead to
resorption of bone and hypercalcaemia. Secondary
hyperparathyroidism is usually a consequence of renal
insufficiency, where chronic hypocalcaemia leads to
parathyroid hyperplasia. Some patients with secondary
hyperparathyroidism then go on to develop the tertiary
form, whereby a parathyroid adenoma arises within a
chronically overstimulated hyperplastic parathyroid gland.
The cardinal radiological feature is subperiosteal bone
resorption. The different sites affected are shown below,
the classical location being the radial aspect of the middle
phalanx of the index and middle fingers. Figure 160b
shows another pattern of erosion band-like zones in the
middle of the terminal tufts. Bone softening may result in
wedged vertebrae, kyphoscoliosis and bowing of long
bones. Parathyroid hormone-stimulated focal osteoclastic
activity can cause brown tumours, which are characteristically expansile, lytic, well demarcated lesions. These can
be the solitary sign of hyperparathyroidism in 3% of cases.
Figure 160e shows a pathological fracture through a brown
tumour.
160b
160c
286
Answer 160
Musculoskeletal Imaging
Practical tips
Further management
160f
160d
160g
160e
160g AP radiograph of right
shoulder demonstrating erosion of
the lateral end of the right clavicle.
160h
287
Chapter 5
PAEDIATRIC IMAGING
289
Paediatric Imaging
CASE 161
161
History
Stillborn fetus.
CASE 162
162
History
An 8-year-old child presented with
headaches.
291
Paediatric Imaging
ANSWER 161
Observations (161)
Discussion
Diagnosis
Thanatophoric dysplasia.
Differential diagnosis
Of lethal neonatal dysplasia:
Osteogenesis imperfecta.
Thanatophoric dysplasia.
Jeunes syndrome (asphyxiating thoracic dysplasia).
The narrow elongated thorax contains a normal size
heart but leaves little room for the lungs. There is an
80% mortality rate from respiratory failure.
Practical tips
It may be possible to identify the specific cause of the lethal
neonatal dysplasia from certain features on the babygram:
Osteogenesis imperfecta will cause generalized
osteopenia with bowing of long bones and multiple
fractures. Multiple wormian bones may also be seen in
the skull.
Thanatophoric dysplasia is associated with a narrow
thoracic cage and telephone handle long bones. The
iliac wings may be small and squared.
Narrowing of the thoracic cage and small squared iliac
wings are also seen in Jeunes syndrome. The ribs may
also be small and horizontal in this condition.
Further management
No further management options.
ANSWER 162
Observations (162)
Discussion
Diagnosis
Suture diastasis due to raised intracranial pressure.
Practical tips
Differential diagnosis
Of the causes of suture diastasis follows the mnemonic
TRIM:
Traumatic diastasis.
Raised intracranial pressure:
Intracerebral tumour.
Hydrocephalus.
Subdural collection.
Infiltration (of the sutures):
Leukaemia.
Lymphoma.
Neuroblastoma.
Metabolic:
Hypoparathyroidism.
Rickets.
Hypophosphatasia.
292
Further management
In most cases, clinical suspicion of elevated intracranial
pressure will lead directly to CT or MRI evaluation, but
this is clearly the next step should such findings be
encountered on plain films with no other explanation.
Paediatric Imaging
CASE 163
163
History
Emergency plain CT of the brain in a
4-year-old child with acute seizures and
hypoxia.
CASE 164
164
History
A newborn presented with breathing
difficulties at birth.
293
Paediatric Imaging
ANSWER 163
Observations (163)
Discussion
Further reading
Diagnosis
ANSWER 164
Observations (164)
An endotracheal tube is in place in a satisfactory position.
The right hemithorax is filled by a large septated lucent
mass, which is causing mediastinal shift to the contralateral
side. The hemidiaphragm is not visualized. The most likely
cause is a congenital diaphragmatic hernia, however cystic
adenomatoid malformation should be considered.
Practical tips
Discussion
Further management
Diagnosis
294
Paediatric Imaging
CASE 165
Case 165
165a
History
A 29-week premature neonate
presented with respiratory distress a few
hours after birth.
295
Answer 165
Paediatric Imaging
ANSWER 165
Observations (165a)
An NG tube lies in the stomach and there is an umbilical
artery catheter in a satisfactory position with the tip at the
level of L4 vertebra. The lungs are small in volume with a
fine reticulogranular pattern affecting all lung zones with
air bronchograms. In view of the history and radiographic
findings, the likely diagnosis is hyaline membrane disease.
Diagnosis
Hyaline membrane disease (HMD).
Discussion
Hyaline membrane disease is one of the most common
causes of respiratory distress in newborns. It is most
common in premature infants but occasionally also occurs
in term infants of diabetic mothers. It is due to lack of
surfactant, an agent responsible for decreasing the surface
tension in alveoli and produced by the type 2 alveolar cells.
Without it the alveoli are poorly distensible and remain
collapsed causing respiratory distress shortly after birth.
Classically the lungs are small in volume with either
ground glass opacity or a fine reticulogranular pattern and
air bronchograms extending out to the lung periphery.
Treatment consists of surfactant therapy and positive
pressure assisted ventilation. However, the elevated airway
pressures may lead to air dissecting through into the
165b
296
Practical tips
Signs of prematurity on the film are reduced
subcutaneous fat and absence of humeral ossification
centres.
Similar lung opacities are seen with neonatal
pneumonia or neonatal retained fluid syndrome,
however unlike HMD, the lung volumes in these
patients will be normal or increased.
165c
Answer 165
Paediatric Imaging
165d
Radiograph
demonstrating
position of an
umbilical
catheter.
Case 166
165d
Further management
Treatment involves oxygenation, ventilation and
administration of surfactant.
Complications of HMD treatment should always be
sought, namely pulmonary interstitial emphysema,
pneumothorax and pneumomediastinum.
CASE 166
166a
History
Unconscious 1-month-old born
at term.
297
Answer 166
Paediatric Imaging
ANSWER 166
Observations (166a)
This axial contrast enhanced CT image shows bilateral and
symmetrical low density in the basal ganglia, involving the
putamina and thalami. There are several possible causes for
this appearance. Hypoxia and hypotension should be selfevident. If not present, levels of glucose and carbon
monoxide should be checked urgently.
Diagnosis
Low-density basal
hypoxia/ischaemia.
ganglia
secondary
to
severe
matter (thalami, putamina and brainstem nuclei), the perirolandic gyri and corticospinal tracts. This case illustrates
such a pattern.
In older children, severe hypoxic-ischaemic injury may
produce a different pattern, that of global cerebral injury.
The resulting cerebral oedema and loss of greywhite
matter differentiation with sparing of the brainstem and
cerebellum can produce the acute reversal sign on CT
described elsewhere (see Case 163).
As a comparative aside, high-density basal ganglia due
to calcification are illustrated (166b) and the differential
diagnosis listed.
Differential diagnosis
Of low-density basal ganglia:
Hypoxia
Hypotension
Hypoglycaemia
Carbon monoxide poisoning
Wilsons disease
Of basal ganglia calcification (mnemonic PIE MAPS):
Physiological the most common cause and
increasingly so with age.
Infection cytomegalovirus (CMV), toxoplasma,
congenital rubella, HIV.
Endocrine hypoparathryroidism (and
pseudo/pseudopseudohypoparathyroidism),
hyperparathyroidism, hypothyroidism.
Metabolic Leigh disease, Fahr disease, Wilsons
disease.
Anoxia at birth, cerebrovascular accident (CVA).
Poisoning carbon monoxide, lead.
Syndromes Downs, Cockaynes syndrome,
neurofibromatosis.
Practical tips
Comparative densities of grey and white matter in the
infant brain are variable on CT depending on stage of
myelination. Normality of the basal ganglia density
can be confirmed by comparison with other grey
matter structures.
MRI is the most sensitive modality for detecting
hypoxic-ischaemic injury but may be logistically
difficult in the acutely unwell infant. Ultrasound may
be practically the easiest imaging option but has
reduced sensitivity.
Further management
Urgent correction of hypoxia, hypotension and
hypoglycaemia is required followed by exclusion of other
causes.
166b
Discussion
Apart from Wilsons disease, the listed differential diagnoses
for this appearance are of acute disorders that ultimately
result in reduced cerebral oxygenation or glucose provision.
The effect of hypoxia/hypotension on the infant brain
depends on whether the infant is term or premature, and
whether the insult is mild or severe. In the premature infant
up to about 34 weeks, it is the deep white matter that is
most vulnerable and hypoxic-ischaemic injury results in
periventricular leukomalacia (PVL) with sparing of subcortical white matter and cortex. Since the corticospinal
tract fibres pass through this area, there is usually resulting
motor impairment.
In the term infant, the pattern of susceptibility is
different. A mild insult results in ischaemia of the
watershed areas of the cerebrum where blood supply is
most tenuous. These are the boundaries between the areas
supplied by the anterior, middle and posterior cerebral
arteries. Vital areas of the brain are protected by redistribution of blood flow. After a severe insult, however, vital
areas of the brain can no longer be protected, and it the
most metabolically active areas at this time of life that are
affected. Thus, ischaemic damage occurs in the deep grey
298
Paediatric Imaging
CASE 167
167a
History
A premature neonate presented with
abdominal distension and sepsis.
CASE 168
168
History
An adolescent male presented with a
history of trauma.
299
Answer 167
Paediatric Imaging
ANSWER 167
Observations (167a)
Discussion
Practical tips
Diagnosis
167b
300
Further management
Mortality rates are dependent on the degree of
prematurity, with rates quoted at 5% in term infants and
12% in premature newborns. Initial treatment is supportive
with bowel rest but if serial radiographs or clinical features
show progression or perforation then surgical resection of
necrotic bowel is required.
Answer 168
Paediatric Imaging
Case 169
ANSWER 168
Observations (168)
No bony injury is seen on this skull radiograph. There are
multiple wormian bones, which at this age is abnormal.
There is a large differential diagnosis but the most likely
cause is idiopathic.
found in the lambdoid, posterior sagittal and temporosquamosal sutures. They are considered abnormal when
seen after 1 year or large and numerous (>10 in number
and larger than 6 x 4 mm).
Practical tips
Diagnosis
Multiple wormian bones.
Differential diagnosis
Of wormian bones, with common causes underlined
(mnemonic PORKCHOPSI):
Pyknodysostosis.
Osteogenesis imperfecta.
Rickets in healing.
Kinky hair syndrome (Menkes).
Cleidocranial dysostosis.
Hypothyroidism/hypophosphatasia.
Otopalatodigital syndrome,
Pachydermoperiostosis.
Syndrome of Downs.
Idiopathic normal in first year of life.
Further management
Management is dependent on the underlying cause.
Further reading
Cremin B, Goodman H, Spranger J, Beighton P (1982).
Wormian bones in osteogenesis imperfecta and other
disorders. Skeletal Radio lo gy 8(1): 3538.
Discussion
Wormian bones are essentially small bones occurring in the
sutures of the calvaria. These intrasutural ossicles are usually
CASE 169
169a
History
A child with a history of partial seizures.
301
Answer 169
Paediatric Imaging
ANSWER 169
Observations (169a)
Axial T2 weighted MR image at the level of the lateral
ventricles. This demonstrates a large cleft extending
through the full thickness of the left cerebral hemisphere
from the surface of the brain to the left lateral ventricle.
The cleft is lined by grey matter and is filled with CSF. The
findings are consistent with schizencephaly.
Diagnosis
Schizencephaly.
Discussion
During gestation, neurones migrate outwards from the
periventricular germinal matrix to form the normal cerebral
cortices. This migration can be interfered with by several
causes including chromosomal abnormalities, but mostly
the reason is unknown. The result is brain tissue lying in
the wrong place, typically grey matter.
Schizencephaly is a cleft extending through the full
thickness of cerebral hemisphere from the ependyma-lined
wall of ventricle to the brain surface. It is lined by pia and
grey matter that usually shows polymicrogyria, and is often
located around the Sylvian fissure. The lateral end of the
cleft may be open and readily apparent (open lip type) but
can sometimes be closely opposed and easy to miss (closed
lip type). However, even the closed lip type will show a
small irregularity in the wall of the ventricle at the site of
302
169b
169c
Answer 169
Paediatric Imaging
Case 170
169d
Practical tips
Subependymal nodules in tuberous sclerosis can also cause
nodularity along the walls of the ventricles. However, the
nodules in this condition show a similar signal to white
matter rather than the grey matter seen in heterotopia.
Further management
Medical management of epilepsy.
CASE 170
170a
History
A newborn who was born at 41 weeks
presented with hypoxia.
303
Answer 170
Paediatric Imaging
ANSWER 170
Observations (170a)
An endotracheal tube has been placed just above the carina.
There is also an NG tube passing into the stomach. There
are bilateral diffuse patchy opacities in both lungs indicative
of widespread atelectasis and patchy consolidation.
However, the lungs appear hyperinflated and there are
small pleural effusions. In view of the history, the
appearances are likely to be due to meconium aspiration
syndrome.
Practical tips
Diagnosis
Meconium aspiration syndrome.
Discussion
Meconium aspiration syndrome is the most common cause
of respiratory distress in newborns born at full or post term.
The large size of the fetus makes delivery difficult. Perinatal
hypoxia and fetal distress lead to meconium defecation in
utero . Aspiration of the meconium into the
tracheobronchial tree then causes obstruction of small
peripheral bronchioles (though only a minority of fetuses
exposed to meconium stained amniotic fluid develop
respiratory symptoms). This results in unevenly distributed
areas of subsegmental atelectasis with alternating areas of
air trapping. The chest radiograph usually begins clearing
within a few days with no long term radiographic sequelae
in the lungs.
170b
304
Further management
Almost all neonates with meconium aspiration syndrome
make a full recovery of their pulmonary function. Upper
airway suction may be employed and ventilatory support
may be required in more severe cases of respiratory distress.
Paediatric Imaging
CASE 171
171a
History
A newborn presented
regurgitation of feeds.
with
CASE 172
172
History
Micturating cystourethrogram
(MCUG) was taken in a male
infant with a previously confirmed
urinary tract infection.
305
Answer 171
Paediatric Imaging
ANSWER 171
Observations (171a)
Further management
Diagnosis
Congenital oesophageal atresia with tracheoesophageal
fistula (TOF).
Discussion
Embryologically the primitive foregut tube separates to
form the trachea and oesophagus. Disorders of this
separation presenting in infancy result in various
combinations of oesophageal atresia and TOF. Presentation
is with excessive drooling, regurgitation of feeds or
symptoms of aspiration depending on the type of
abnormality present.
In 90% of cases there is a component of oesophageal
atresia, and the majority of these have an associated
tracheoesophageal fistula. Such a fistula can be proximal,
distal or both (i.e. between the trachea and the proximal
oesophageal segment, the distal segment or both). This
case demonstrates the most common subtype (seen in
around 80%) where there is oesophageal atresia and a distal
TOF. The atresia results in drooling and regurgitation
while the distal TOF results in passage of air from trachea
into stomach and thus the rest of the bowel.
A minority of cases have TOF without oesophageal
atresia and are more likely to present with coughing or
choking during feeds and ultimately aspiration pneumonia.
An example is shown (171b) where water-soluble contrast
has been injected via an NG tube in the oesophagus and is
seen to pass into the trachea via the fistula.
171b
Practical tips
Oesophageal atresia CXR shows a retrotracheal
distended pouch of proximal oesophagus and a
feeding tube may be coiled within it after attempted
passage.
A gasless abdomen indicates no fistula or a proximal
fistula.
Gas in the abdomen indicates presence of a distal
fistula.
Look for consolidation suggesting associated
aspiration pneumonia.
Oesophageal atresia and TOF can be part of a
VACTERL syndrome so check the CXR for
abnormalities:
Vertebral anomalies.
Anorectal anomalies.
Cardiovascular anomalies.
Tracheo-Esophageal fistula.
Renal anomalies.
Limb anomalies.
306
Answer 172
Paediatric Imaging
Case 173
ANSWER 172
Observations (172)
This MCUG study shows a transverse filling defect at the
posterior urethra with distension of the proximal posterior
urethra. The findings are consistent with posterior urethral
valves.
Diagnosis
Posterior urethral valves.
Discussion
Congenital presence of thick folds of mucous membrane
in the posterior urethra is the most common cause of
urinary tract obstruction in boys. The condition is often
suspected on prenatal US where it can lead to
oligohydramnios, hydronephrosis, prune belly and urine
ascites or urinoma due to leak. If obstruction occurs early in
utero then multicystic dysplastic kidney may result. After
birth, MCUG is the investigation of choice to outline the
transverse filling defect caused by the thick mucosal folds.
Distension and elongation of the proximal part of the
CASE 173
Practical tips
Note how diagnosis is still possible when the catheter is in
situ during the voiding phase of the MCUG (172).
Further management
Urological surgical intervention is required with initial
treatment aimed at relieving bladder outlet obstruction and
ablating the valves. Secondary treatment may be required
for vesicoureteral reflux, urinary tract infections, urinary
incontinence and renal dysfunction.
173a
History
A newborn presented with abdominal
distension and failure to pass
meconium.
307
Answer 173
Paediatric Imaging
ANSWER 173
Observations (173a)
An NG tube is in the stomach. There are multiple dilated
loops of bowel in the abdomen. No fluid levels are seen
within the bowel suggesting that the appearances may be
due to meconium ileus. However, other pathologies such as
Hirschsprungs disease and imperforate anus should be
considered.
Practical tips
Diagnosis
Meconium ileus.
Differential diagnosis
Hirschsprungs disease.
Imperforate anus.
Ileal atresia.
Inguinal hernia.
Discussion
Meconium ileus is the term used to describe small bowel
obstruction in neonates secondary to inspissated meconium
pellets impacted in the distal ileum. The vast majority prove
to have cystic fibrosis and this is the earliest manifestation of
the disease. The diagnosis is confirmed by performing a
contrast enema, which demonstrates multiple round filling
defects (the inspissated meconium) in the distal ileum and
proximal colon (173b). The colon may be very narrow on
the contrast study if it has been unused due to antenatal
obstruction, whereby it is termed a microcolon. The enema
Further management
Water-soluble contrast enema can be useful for both
diagnosis and treatment.
All patients with meconium ileus should have a sweat
test to exclude underlying cystic fibrosis.
173b
308
Paediatric Imaging
CASE 174
174a
History
A 4-year-old child presented with
fever and abdominal pain.
CASE 175
175
History
A 4-month-old child presented
with persistent irritability.
309
Answer 174
Paediatric Imaging
ANSWER 174
Observations (174a)
Axial CT of the abdomen with oral contrast and IV contrast
in portal phase. There is a large slightly heterogeneous mass
arising from the right kidney. The mass does not enhance as
much as the renal parenchyma. There is local mass effect
with displacement, but no invasion of the right lobe of liver
or encasement of vessels. A small mass of similar density is
seen near the hilum of the left kidney. The appearances
suggest bilateral Wilms tumours.
Diagnosis
Differential diagnosis
Neuroblastoma.
Discussion
Wilms tumour (nephroblastoma) is the most common
abdominal malignancy in young children, most commonly
presenting at age 34 years. The most frequent presentation
is with abdominal mass, though hypertension, pain, fever
and haematuria also occur. The tumour usually grows to a
large size, often measuring over 10 cm. Radiological
features include:
Exophytic mass displacing rather than encasing
adjacent structures.
Less contrast enhancement than normal renal
parenchyma.
Cystic/necrotic areas give it a heterogeneous
appearance.
Invasion of the renal vein and inferior vena cava may
occur in up to 10%.
Tumours are bilateral in 10% and this indicates background
nephroblastomatosis, a state of persistent nephrogenic
blastema that is a precursor to Wilms. Wilms tumour is
associated with the BeckwithWiedemann syndrome
(macroglossia, visceromegaly and omphalocele). Other
associations include aniridia and hemihypertrophy.
The main differential diagnosis is neuroblastoma, a
common malignant tumour of the neural crest that presents
in a similar way to Wilms tumour with a painful abdominal
mass and fever. Typical age of presentation is slightly earlier
however (under 2 years). Hormone secretion from the
tumour (such as catecholamines) may cause other signs,
including hypertension and opsoclonus (chaotic jerky eye
movements). It can arise anywhere in the sympathetic
neural chain including the adrenal gland and the abdominal
sympathetic chain.
Further management
Treatment is with radical nephrectomy and chemotherapy.
Preoperative chemotherapy is advocated in cases of bilateral
Wilms tumours and when there is IVC extension of
tumour (occurs in ~5%).
174b
Practical tips
Always check for bilateral tumours when Wilms is
suspected.
Differentiating between neuroblastoma and Wilms
tumour can be difficult radiologically but there are
some specific features that can help:
310
Answer 175
Paediatric Imaging
Case 176
ANSWER 175
Observations (175)
There is bilateral symmetrical thick, smooth periosteal
reaction affecting the diaphyses of the long bones. There
is no fraying or splaying of the metaphyses to suggest
rickets. The most likely diagnosis at this age is Caffeys
disease, however other possibilities such as leukaemia need
to be considered.
Diagnosis
Caffeys disease.
Differential diagnosis
Of bilateral diffuse periosteal reaction in childhood:
Normal variant before the age of 4 months.
Caffeys disease.
Leukaemia.
Scurvy.
Rickets.
Hypervitaminosis A.
Non accidental injury (NAI).
Practical tips
If there is diffuse periosteal reaction with fractures of
differing ages, NAI must be considered.
With rickets, splaying and fraying of the metaphyses
will be seen.
Further management
When NAI is considered then a careful analysis of previous
radiographs, the clinical presentation and consultation with
a specialist paediatric radiologist must be carried out
because of the repercussions of a misdiagnosis.
Discussion
Infantile cortical hyperostosis (Caffeys disease) is a
proliferative bone disease seen in patients under the age of
CASE 176
176a
History
None available.
311
Answer 176
Paediatric Imaging
ANSWER 176
Observations (176a)
There is widespread bilateral decreased bone density with
healing insufficiency fractures of the radius and ulna
bilaterally. These are associated with thick smooth periosteal
reaction and there is fraying and splaying of the metaphyses.
The features are characteristic of rickets.
Diagnosis
Rickets.
Differential diagnosis
Hypophosphatasia.
Discussion
Rickets is most commonly due to insufficient biologically
active vitamin D, though impaired calcium absorption or
excessive phosphate excretion can occasionally be to blame.
In the western world, pure dietary deficiency of vitamin D
is rarely the sole cause; more often it is due to
malabsorption or impaired vitamin D metabolism in the
liver or kidney.
Rickets is essentially osteomalacia during enchondral
bone growth. Portions of the skeleton that have already
matured show features of osteomalacia, but loss of normal
maturation and mineralization of cartilage cells at the
176b
176c
312
Answer 176
Paediatric Imaging
Case 177
Further management
Rickets is now usually identified early and treated with
vitamin D supplements. Significant pelvis deformity and
gait disturbances are now rarely seen in the developed
world.
Practical tips
The earliest sign of rickets on the plain film is a
widening of the growth plate.
Loosers zones are rare in rickets compared to
osteomalacia in the fused skeleton.
CASE 177
177a
History
None available.
313
Answer 177
Paediatric Imaging
ANSWER 177
Observations (177a)
Discussion
Diagnosis
Ellisvan Creveld syndrome.
Differential diagnosis
Of causes of polydactyly:
Idiopathic.
Ellisvan Creveld syndrome.
Carpenter syndrome.
Polysyndactyly syndrome.
Practical tips
Of causes of syndactyly:
Idiopathic.
Aperts syndrome.
Carpenter syndrome.
Downs syndrome.
Polands syndrome.
Neurofibromatosis.
Further management
177b
314
Paediatric Imaging
CASE 178
Case 178
178a
History
None available.
178b
315
Answer 178
Paediatric Imaging
ANSWER 178
Observations (178a, 178b)
Pyles disease.
Differential diagnosis
Practical tips
In this case:
Craniometaphyseal dysplasia.
NiemannPick disease.
Gauchers disease.
Diagnosis
Discussion
Pyles disease is also known as metaphyseal dysplasia. It is
a rare autosomal recessive disorder characterized by flaring
of the ends of long bones with relative constriction and
sclerosis of the central portion of the shafts. Affected
patients are usually asymptomatic and genu valgus
Further management
This condition is usually asymptomatic and requires no
direct management.
178a
316
Paediatric Imaging
CASE 179
Case 179
179a
History
None available.
179b
317
Answer 179
Paediatric Imaging
ANSWER 179
Observations (179a, 179b)
Discussion
Diagnosis
Osteogenesis imperfecta.
Differential diagnosis
Of wormian bones with common causes underlined
(mnemonic PORKCHOPSI):
Pyknodysostosis.
Osteogenesis imperfecta.
Rickets in healing.
Kinky hair syndrome (Menkes).
Cleidocranial dysostosis.
Hypothyroidism/hypophosphatasia.
Otopalatodigital syndrome.
Pachydermoperiostosis.
Syndrome of Down.
Idiopathic normal in first year of life.
318
Practical tips
Multiple fractures in children should raise suspicion of non
accidental injury (NAI) and sometimes differentiating this
from osteogenesis imperfecta can be difficult. Predominantly osteogenesis fractures are diaphyseal compared with
metaphyseal NAI fractures but this is not always the case.
Further management
Early medical intervention to increase bone mineral density
and surgical intervention to treat/correct scoliosis and treat
fractures mean that a multidisciplinary approach to the
ongoing treatment is required.
Paediatric Imaging
CASE 180
180a
History
A child presented
vomiting and ataxia.
with
CASE 181
181a
History
A 2-month-old baby presented with
cyanosis.
(see page 322 fo r case answer)
319
Answer 180
Paediatric Imaging
ANSWER 180
Observations (180a)
A series of axial MRI images of skull show a well defined
hyperdense mass in the cerebellar vermis causing
compression and anterior displacement of the 4th ventricle
with obstructive hydrocephalus. A small amount of oedema
surrounds the mass. The features are typical of a
medulloblastoma.
Diagnosis
Medulloblastoma.
Differential diagnosis
Of posterior fossa tumour in children:
Medulloblastoma:
Predominantly midline posterior to 4th ventricle.
Hyperdense on CT with oedema.
Avid enhancement.
20% calcify, 50% necrose.
Juvenile pilocytic astrocytoma:
Typically paracentral, posterior to 4th ventricle.
Majority are cystic with an enhancing mural
nodule, the remainder are solid.
20% calcify; oedema is rare.
Ependymoma:
Arises within 4th ventricle.
Heterogeneous appearance and enhancement.
50% calcify.
180b
320
Discussion
Medulloblastoma is the second most common paediatric
brain tumour and the most common in the posterior fossa.
It is a type of primitive neuroectodermal tumour (PNET)
Answer 180
Paediatric Imaging
180c
Practical tips
Make sure the post contrast scan looking for drop
metastases is done preoperatively as postoperative
haemorrhage and granulation tissue can cause
confusion.
Haemangioblastoma is primarily a tumour of adults
but can be seen in adolescents in the posterior fossa
when part of von HippelLindau syndrome. It is
typically a cystic mass with enhancing mural nodule,
so has similarities with pilocytic astrocytoma.
Further management
MRI of the spine with intravenous contrast enhancement
should be undertaken to look for drop metastases.
Neurosurgical assessment is then clearly appropriate.
Further reading
Koeller K, Rushing E (2003). From the archives of the
AFIP: medulloblastoma: a comprehensive review with
radiologic-pathologic correlation. Radio Graphics 23:
16131637.
180d
321
Answer 181
Paediatric Imaging
ANSWER 181
Observations (181a)
There is a right sided aortic arch. The heart is boot shaped
indicating right ventricular hypertrophy. The lungs are not
plethoric, in fact there is a reduction in the calibre of the
pulmonary vessels. Overall, the features are suggestive of
Fallots tetralogy.
Diagnosis
Tetralogy of Fallot.
Differential diagnosis
Of conditions associated with a right sided aortic arch:
Truncus arteriosus.
Tetralogy of Fallot.
Transposition of great vessels.
Pulmonary atresia.
Ventricular septal defect (VSD).
Discussion
Tetralogy of Fallot is one of the most common causes of
cyanotic congenital heart disease and is composed of the
following: obstruction of right ventricular outflow, large
VSD, right ventricular hypertrophy and an overriding aorta.
Radiological features on CXR are:
Concavity in the region of the pulmonary artery,
which is small.
Enlarged aorta.
Practical tips
Fallots tetralogy, pulmonary stenosis and tricuspid
atresia cause cyanosis with oligaemic lungs.
Transposition of the great vessels, truncus arteriosus
and total anomalous pulmonary venous drainage
cause cyanosis with plethoric lungs.
Further management
Cardiology referral for echocardiography and consideration
for a palliative shunt or complete surgical repair.
181b
322
Paediatric Imaging
Case 182
CASE 182
History
An 11-month-old child with cleft palate
and neurological abnormalities.
182
323
Answer 182
Paediatric Imaging
ANSWER 182
Observations (182)
The posterior fossa is enlarged with absence of the
cerebellar vermis, hypoplasia of the cerebellar hemispheres
and the presence of a large posterior fossa cyst, which is in
continuity with the 4th ventricle. A ventriculoperitoneal
shunt is seen in the right lateral ventricle. There is
ventriculomegaly but the sulci are not effaced. The features
are consistent with DandyWalker malformation.
Diagnosis
DandyWalker malformation.
Discussion
The DandyWalker malformation is a congenital
malformation whereby the posterior fossa is enlarged and
the tentorium cerebelli is elevated, however the cerebellar
hemispheres are hypoplastic. Absence or hypoplasia of the
cerebellar vermis is present with a posterior fossa cyst
directly connected to the 4th ventricle. Ventriculomegaly
and dysgenesis of the corpus callosum are associated
findings. Most affected patients die in infancy. The less
severe form, DandyWalker variant, is more common and
is not associated with enlargement of the posterior fossa.
The associated posterior fossa cyst is smaller and the
cerebellar vermis is hypoplastic rather than absent.
Practical tips
A mega cisterna magna may mimic DandyWalker
malformation, however there is no cerebellar vermis
abnormality, continuity with or abnormality of the
4th ventricle.
A posterior fossa arachnoid cyst may also mimic these
appearances.
If the posterior fossa is not enlarged and the
cerebellar vermis is hypoplastic rather than absent,
consider DandyWalker variant rather than
malformation.
Further management
The associated CNS abnormalities can be better identified
on MRI. Treatment often involves insertion of a ventricular
shunt, as in this case, to relieve hydrocephalus. Genetic
counselling may be appropriate for the family.
182
182 Absence of cerebellar vermis (left); sulci are not effaced (bottom
left); ventriculomegaly (right); hypoplasia of cerebellar hemispheres
(top right).
324
Paediatric Imaging
CASE 183
Case 183
183
History
A newborn presented with bilious
vomiting.
325
Answer 183
Paediatric Imaging
ANSWER 183
Observations (183)
Dextrocardia is present with situs solitus. A right femoral
line is noted. An NG tube is present in the stomach, which
is dilated with air. There is a double bubble appearance
of the dilated stomach and duodenal cap with no gas seen
distally. The findings are consistent with duodenal atresia.
Diagnosis
Duodenal atresia, possibly part of VACTERL syndrome.
Differential diagnosis
Of double bubble on abdominal radiograph:
Annular pancreas.
Duodenal diaphragm.
Peritoneal band.
Choledochal cyst.
Discussion
Duodenal atresia is due to failure of recanalization of the
duodenum at around 10 weeks and is the most common
cause of congenital duodenal obstruction. The other major
cause is annular pancreas, and both are associated with
Downs syndrome. The obstruction is just beyond the
ampulla in the majority of cases and the double bubble
results from gas-fluid levels in the first part of duodenum
and stomach. Gas may be seen more distally in the bowel
if there is duodenal stenosis rather than complete atresia
(though atresia is twice as common).
183
326
Practical tips
Always check the double bubble radiograph for
VACTERL associations, e.g. vertebral anomalies on the
film.
Further management
Fluid and electrolyte imbalance must be corrected along
with decompression of the stomach via NG tube insertion.
Surgical correction is then required, usually with good
outcome.
Paediatric Imaging
CASE 184
Case 184
184a
History
A child with dwarfism.
327
Answer 184
Paediatric Imaging
ANSWER 184
Observations (184a)
Lateral spinal radiograph shows vertebral bodies are
flattened with central beaking anteriorly. There is also
widening of the intervertebral disc spaces and posterior
vertebral scalloping. The findings are suggestive of
Morquios syndrome.
Diagnosis
Morquios syndrome.
Differential diagnosis
Hurlers syndrome.
Achondroplasia.
Discussion
Morquios syndrome is a rare metabolic disorder classified
as one of the mucopolysaccharidoses. It is autosomal
recessive and presents in childhood with characteristic
skeletal deformity and dwarfism. Patients also have deafness
and cardiac dysfunction, however they may well live to
adulthood. Atlantoaxial subluxation is a feature and there
may be absence of the odontoid peg. Radiograph of the
184b
184c
328
Answer 184
Paediatric Imaging
Lower limbs:
Sloping of superior margin of tibial plateau laterally
(184d).
Genu valgus deformity (184d).
Hands and feet:
Proximal tapering of the metacarpal bones
producing bullet-shaped metacarpals (184e).
Short widened tubular bones with metaphyseal
irregularity (184e).
Further management
Practical tips
It may be very difficult on imaging to differentiate
Morquios from achondroplasia or the other mucopolysaccharidoses. Some features may help radiological
differentiation:
Caudal narrowing of the spinal canal is not a feature of
the mucopolysaccharidoses however it is present in
achondroplasia; therefore assess the interpedicular
distance on the AP of the spine.
The anterior vertebral body beaks in Morquios tend
to be in the Middle of the vertebral body whereas in
Achondroplasia and Hurlers syndrome they are
Anteroinferior.
184d
Further reading
Wakely S (2006). The posterior vertebral scalloping sign.
Radio lo gy 239: 607609.
184e
329
Chapter 6
BREAST IMAGING
MAMMOGRAPHY
Until recently, most mammographic images were obtained
as hard film copy. Today, many breast imaging departments
have full-field digital mammography (FFDM) equipment
enabling electronic storage and image manipulation to aid
interpretation. In standard mammography two views of
each breast are taken: the mediolateral oblique (MLO)
projection and the craniocaudal (CC) or superioinferior
(SI) projection. Particular care is taken with image
acquisition in mammography inadequate positioning may
result in suboptimal images and missed diagnoses. During
image acquisition the breast is compressed to even out the
tissue thickness and hold the breast still in order to
minimize blurring of the image caused by motion.
When viewing bilateral mammograms, both sides are
assessed at the same time in a back-to-back or mirror
image format, as shown opposite. By convention, the CC
views are arranged with the lateral (outer) aspect at the top
of the image and the medial (inner) at the bottom of the
image. On the MLO view the inferior extent of the pectoral
muscle should be at least at nipple level. Small densities and
areas of asymmetry may be more apparent when viewing
both sides simultaneously. In addition to a global overview,
specific inspection of all areas is required. The examination
may be evaluated by dividing each image into thirds and
going back and forth between the right and left sides
looking specifically for global and focal asymmetry,
distortion, possible masses and calcification. Other signs to
assess for are skin and nipple retraction, skin thickening,
trabecular thickening and axillary lymphadenopathy. Small
masses and areas of microcalcification should be looked at
under magnification, using workstation tools with digital
images or a magnifying glass with conventional analogue
films. Previous mammograms may aid interpretation and
assessing the significance of focal findings.
Left MLO
Right MLO
Left CC
Right CC
331
Breast Imaging
BREAST ULTRASOUND
Breast ultrasound is used to characterize abnormalities
detected by physical examination or potential abnormalities
seen on mammography. Ultrasound imaging can help to
determine if an abnormality is solid (which may be a
malignancy, a benign tumour such as a fibroadenoma or
other nonmalignant tissue) or fluid-filled (such as a benign
cyst). As ultrasound provides real-time images, it is often
used to guide biopsy procedures.
BREAST MR IMAGING
MR imaging of the breast is not usually a replacement for
mammography or ultrasound imaging but rather a
supplemental tool for detecting and staging breast cancer
and other breast abnormalities. MR imaging of the breast
may be performed to:
Identify early breast cancer not detected through
other means, especially in women with dense breast
tissue and those at high risk for the disease.
Evaluate abnormalities detected by mammography or
ultrasound in equivocal cases.
Assess multiple tumour locations, especially prior to
breast conservation surgery.
Assess the effect of chemotherapy.
Determine the integrity of breast implants.
Dynamic contrast enhanced MRI to evaluate the breast
parenchyma for cancer has a high sensitivity (~90%), with
a lower variable specificity (4080%) a relatively high
number of false-positive results can be generated. Close
attention to scanning technique, full standard breast
imaging workup and integration of all breast imaging
findings during scan interpretation increases diagnostic
yield.
COMPUTER-AIDED DETECTION
Computer-aided detection (CAD) uses pattern recognition
software to help read medical images. Such techniques
bring features on medical images to the attention of the
film reader and may decrease false-negative readings when
films are single read. The use of CAD has been evaluated in
both mammography and breast MRI, but has not been
used widely in the UK, where screening mammograms are
interpreted by two human readers.
332
Breast Imaging
CASE 185
Case 185
185
History
Screening mammograms in a 61-yearold woman.
333
Answer 185
Breast Imaging
ANSWER 185
Observations (185)
Practical tips
Diagnosis
Breast carcinoma (invasive ductal carcinoma; IDC).
Differential diagnosis
For stellate lesion:
Malignancy.
Postsurgical scar (ask about a history of previous
surgery).
Fat necrosis (often post-trauma or surgery).
Radial scar (a lesion with central scar formation and
radiating hyperplastic ducts).
Discussion
The most common mammographic sign of an invasive
breast cancer is a mass: a space-occupying lesion that is seen
in at least two mammographic projections. The typical
features on mammography of a mass due to an invasive
cancer are irregular shape, ill-defined or spiculate margins
and high radiographic density. In about 40% of cases the
mass is associated with calcification of malignant
configuration pleomorphic and irregular.
Mammographic ill-defined masses require further
evaluation. Ultrasound will often demonstrate a hypoechoic
irregular mass with ill-defined borders. Image guided core
biopsy should be performed if not possible with ultrasound then under mammography guided stereotaxis.
In such cases, ultrasound of the ipsilateral axilla should
be performed and any nodes of suspicious configuration
should undergo fine needle aspiration (FNA) or core biopsy
to assess for metastatic spread (see introduction to this
chapter).
Invasive ductal carcinoma is the most common
indistinctly marginated carcinoma. IDC may be divided
into various specific subtypes: the majority of ductal
malignancies fall into the generalized category of lesions
that are undifferentiated and have no particular
distinguishing histological features; these are termed not
otherwise specified (NOS) and account for 65% of invasive
breast cancers.
334
Further management
Recall for clinical examination, ultrasound +/ further
mammographic views with the intention to proceed to
image guided core biopsy.
Breast Imaging
CASE 186
Case 186
186a
History
A 56-year-old woman with a firm mass
in the central left breast.
186b
335
Answer 186
Breast Imaging
ANSWER 186
Observations (186a, 186b)
Bilateral mammograms show that in the upper central and
lateral aspects of the left breast there is extensive
pleomorphic microcalcification. Within the left axilla there
is a 21 mm diameter rounded node. The right breast
appears normal. Ultrasound of the superior central left
breast demonstrates an irregular solid mass.
The extensive microcalcification is of a configuration
suspicious for malignancy in the central left breast. There
is possible metastatic spread to the large axillary node. The
ultrasound demonstrates a probable malignancy. Further
investigation with urgent biopsy of the lesion is required.
Diagnosis
Ductal carcinoma in situ (DCIS) with involved axillary
nodes.
Differential diagnosis
For pleomorphic calcification on mammograms:
DCIS.
Atypical ductal hyperplasia.
Fat necrosis.
Fibrocystic change.
For enlarged axillary nodes:
Ipsilateral breast malignancy.
Infection/inflammation of ipsilateral breast or arm.
Collagen vascular disease/rheumatoid arthritis.
Lymphoproliferative diseases: lymphoma and
leukaemia.
Metastases (melanoma, lung, contralateral breast).
HIV adenopathy.
Further management
Further imaging assessment is suggested: mammographic
magnification orthogonal views (typically craniocaudal and
mediolateral) may evaluate morphology and distribution
of the microcalcification. Ultrasound guided biopsy of the
solid lesion and mammographic stereotactic biopsies to
obtain a sample containing calcification should be
performed. The suspicious node should be sampled under
ultrasound guidance. In this case, the biopsies showed:
ultrasound solid lesion invasive carcinoma; stereotactic
cores DCIS; axillary node malignant cells.
Once a diagnosis of malignancy has been established,
surgical referral is required. In this case the patient
underwent a mastectomy and axillary lymph node
clearance. Histological findings were of a 12 mm IDC in
the superior central breast with extensive (7 cm)
intermediate grade DCIS; 4 out of 15 axillary nodes were
involved with tumour.
186a
Discussion
Pleomorphic microcalcification may be defined as irregular
calcifications of varying sizes and shapes, usually <0.5 mm
in size. Orthogonal mammographic views may clarify the
characteristics for instance, linear and segmental
distributions suggest that the calcification is ductal in
origin, whereas regional or diffuse multiple bilateral groups
are less likely to represent a ductal process.
A small percentage of malignant lesions arise from the
stromal elements of the breast. Ninety per cent of breast
cancers have cellular features that are similar to ductal
epithelium and are consequently classified as ductal cancers.
When confined to the duct they are termed ductal
carcinoma in situ (DCIS). When the cells have breached
the basement membrane around the duct and invaded the
surrounding tissues, they are termed invasive ductal
carcinoma (IDC).
The diagnosis of DCIS is associated with the possibility
of associated invasive disease. If no invasive focus is
identified on mammography further assessment with
ultrasound and possibly MR imaging with a view to
potentially finding an invasive component may be
performed.
Practical tips
Not infrequently, microcalcification is of equivocal
configuration if there is doubt there is a low
threshold to proceed to biopsy.
336
Breast Imaging
CASE 187
CASE 188
History
History
187a
188
187b
337
Breast Imaging
ANSWER 187
Observations (187a, 187b)
The breasts are heterogeneously dense. There are semiovoid low-density opacities in both breasts. There is a large
dominant lesion in the upper outer left breast.
Ultrasound of the left breast lump demonstrates a well
defined smooth margined anechoic mass with through
transmission. The appearance of the lesion assessed with
ultrasound is in keeping with a benign simple cyst.
Diagnosis
Benign simple cysts.
Differential diagnosis
Of a smooth low-density lesion on mammography:
Simple cyst.
Oil cyst.
Fibroadenoma.
~1.5% of circumscribed round lesions may be
malignancies.
Practical tips
Discussion
Further management
ANSWER 188
Observations (188)
There is diffuse trabecular prominence throughout the right
breast which is of generalized increased density. The skin
is thickened. There are enlarged nodes in the right axilla.
The left breast is normal.
Diagnosis
Probable inflammatory right breast cancer with axillary
nodal involvement.
Differential diagnosis
For diffuse trabecular/skin thickening:
Post radiotherapy change.
Progressive systemic sclerosis.
Obstruction of the superior vena cava.
Lymphoma.
Infection/inflammatory mastitis most common in
lactating women.
Trauma.
Generalized oedema due to causes such as congestive
heart failure or nephritic syndrome.
Discussion
Ultrasound or MR imaging may be used to find a discrete
338
Practical tips
Patients often undergo neoadjuvant chemotherapy
prior to mastectomy.
Consider inflammatory breast cancer when an
inflamed breast fails to respond to a brief course of
antibiotics.
Breast Imaging
CASE 189
CASE 190
History
History
189
190
339
Breast Imaging
ANSWER 189
Observations (189)
In the left breast there is a fan shaped density emanating
from the nipple which gradually blends into surrounding
fatty tissue. The right breast appears normal.
Diagnosis
Gynaecomastia.
Differential diagnosis
Of a breast lump in a male:
Gynaecomastia.
Male breast cancer (circumscribed or spiculate mass
usually evident; often eccentric to the nipple).
Pseudogynaecomastia (fatty enlargement with no
ductal or stromal proliferation; secondary to obesity).
Diabetic mastopathy (firm mass in patient with
longstanding type 1 diabetes mellitus).
Abscess (erythema; acute history).
Discussion
Gynaecomastia usually appears as a fan shaped density
emanating from the nipple, gradually blending into
surrounding fat. Three mammographic patterns of
gynaecomastia have been described: nodular, dendritic and
diffuse. There may be prominent extensions into the
surrounding fat and, in some cases, an appearance similar
to that of a heterogeneously dense female breast. Although
Further management
On the diagnosis of gynaecomastia it is important to
correlate the imaging findings with the clinical history.
Many cases of gynaecomastia are idiopathic but
underlying causes should be investigated serum hormone
levels should be taken. Ask for a drug history and the
presence of signs of chronic renal insufficiency, cirrhosis
and a testicular mass; other imaging investigations
pertaining to the patient may raise one of these
possibilities.
ANSWER 190
Observations (190)
Differential diagnosis
Discussion
Diagnosis
340
Practical tips
If calcification is of equivocal configuration, there is a low
threshold to proceed to biopsy.
Further management
No intervention required. Routine recall for screening.
Breast Imaging
CASE 191
Case 191
191a
History
A 44-year-old woman with fullness in
the medial left breast on clinical
examination. There is no discrete mass.
191b
191c
341
Answer 191
Breast Imaging
ANSWER 191
Observations (191a, 191b, 191c)
Discussion
Diagnosis
Invasive lobular carcinoma (ILC).
Differential diagnosis
For mammographic asymmetry:
Normal variant dominant glandular tissue (stable
compared to previous mammograms, usually
nonpalpable).
Summation artefact due to superimposed normal
structures (thins on spot compression mammograms;
ultrasound normal).
Hormone influences between 20% and 40% of
women commenced on hormone replacement therapy
(HRT) develop increased density which may be focal
or generalized.
Malignancy (invasive ductal carcinoma [IDC], invasive
lobular carcinoma [ILC], ductal carcinoma in situ
[DCIS]) this must be considered when there is
asymmetrical density that is newly developed when
compared to previous mammograms, and that persists
on spot compression mammograms; and/or when
encountering a hypoechoic mass on ultrasound.
Practical tips
Check thoroughly for multicentric and contralateral
malignancies, which are of a high proportion in ILC.
Further management
Please refer to the introductory section in this chapter for
indications for breast MRI.
191c
342
Further Reading
Aids to Radio lo gical Differential Diagno sis
Stephen Chapman, Richard Nakielny
WB Saunders, 4th edn, 2003
343
344
opacification
ground glass 29
high-density 20
over hemithorax 14
ophthalmic vein (superior)
distension 103
optic nerve thickening 99
orbital pseudotumour 88
osteochondritis dissecans 131
osteochondroma 136
osteogenesis imperfecta 127
osteoid osteoma 148
osteomyelitis 158
osteonecrosis, spontaneous 131
osteopoikilosis 122
osteosarcoma 125, 134, 136
osteosclerosis
in adults 140
in children 119, 145
pancreas, annular 44
parosteal osteosarcoma 136
pear shaped bladder (HELP) 70
pencil in cup deformity 143
periarticular soft tissue calcification
121
perilymphatic nodules 1
periosteal reaction, diffuse bilateral
157, 175
periventricular white matter 97
permeative bone lesions 118
persistent dense nephrogram 58
pilocytic astrocytoma, juvenile 104
pineal region mass 92
platyspondyly 154
pleomorphic calcification: breast
186
pleural lesions 9
pleural thickening, diffuse 2
pneumoconiosis, mass lesion with
7
pneumomediastinum, causes of 34
pneumonia, flitting 21
pneumoperitoneum, causes of 75
polycystic liver disease 80
polydactyly, causes of 177
pontine glioma 105
posterior fossa tumour 180
posterior mediastinal mass 10
posterior vertebral scalloping 151
primary sclerosing cholangitis (PSC)
45
pseudarthrosis, congenital 127
pseudotumour, orbital 88
psoriatic arthropathy 143
pulmonary fibrosis
lower zone 17
upper zone 18
pulmonary nodules 8, 33
Pyles disease 178
radiolucent bladder filling defects on
IVU 56
345
General Index
Figures refer to case numbers
achalasia 57
achondroplasia 151, 184
acoustic neuroma 94
acromegaly 98
acro-osteolysis 152
adamantinoma 95
adenomyosis 81
adrenal adenoma 67
air bronchogram, hyaline membrane
disease 165
air trapping, meconium aspiration
syndrome 170
albendazole 40
alcohol consumption/alcoholism
105
erosive gastritis 54
pancreatitis 72
allergic bronchopulmonary
aspergillosis (ABPA) 21, 36
alveolar microlithiasis 20
ameloblastoma 95
amputation, lymphoma recurrence
118
aneurysmal bone cyst 95, 115
angiodysplasia 39
angiography
arteriovenous malformations 33
coarctation of the aorta 32
focal nodular hyperplasia 85
mesenteric 39
angiomyolipoma 48
angiotensin converting enzyme
(ACE) serum levels 1
ankylosing spondylitis 18, 116,
120, 127
anterior cruciate ligament 159
antinuclear antibodies (ANA) 17
anus, imperforate 44, 173
aorta, coarctation 32
aortic aneurysms, thoracic 10
aortic arch, right sided 26, 181
aortic stenosis, angiodysplasia
association 39
aortic valve, bicuspid 32
aortitis, ankylosing spondylitis 18
Aperts syndrome 177
aphthous ulcers, Crohns disease 53
arachnoid cyst 89, 94
arteriovenous malformations 102
arthropathy of haemochromatosis
50
asbestosis 3, 15
Aspergillus
allergic bronchopulmonary
aspergillosis 21, 36
cystic fibrosis 36
346
secondary infection 7
upper lobe segment 18
aspiration pneumonia 171
asthma
allergic bronchopulmonary
aspergillosis 21
global cerebral anoxia 114
atelectasis
meconium aspiration syndrome
170
rounded 15
atherosclerotic disease
coronary artery 30
renal artery stenosis 58
subclavian steal syndrome 19
atlantoaxial subluxation 120, 184
atrial fibrillation 23
Auerbachs plexus degeneration 57
autonephrectomy, renal tuberculosis
74
avascular necrosis of femoral head
117, 135, 139
balloon occlusion, pulmonary
arteriovenous malformation 33
balloon angioplasty, subclavian steal
syndrome 19
bamboo spine 18, 120
barium aspiration 20
basal ganglia, low-density 166
biliary stasis, Carolis disease 80
biliary tree
gas 41, 47
hepatic cysts 80
biopsy
core 185
ultrasound guided 186
birds beak sign 46, 57
bladder
calcification 62
cancer 62
neurogenic 60
pear shaped 70
squamous cell carcinoma 62
stones 56
trabeculation 172
tuberculosis 62, 74
bladder tumour, pseudoureterocele
56
blood transfusion, iron overload 50
bone
achondroplasia 151, 184
acromegaly 98
aneurysmal cyst 95, 115
Caffeys disease 175
chondrosarcoma 141
diaphyseal aclasis 130
Ellisvan Creveld syndrome 177
General Index
bronchiectasis
airway walls 27
cystic in allergic
bronchopulmonary aspergillosis
21
traction 1
bronchioles, mucoid impaction 21
bronchogenic carcinoma
metastatic 24
miliary metastases 4
bronchogenic cyst, intrapulmonary
13
brown tumours 160
bucket handle tear, meniscal 159
bulla, right sided 35
butterfly glioblastoma multiforme
110
caecal volvulus 46
Caffeys disease 175
calcification
ankylosing spondylitis differential
diagnosis 18
atrial 23
basal ganglia 166
benign breast 190
benign breast cysts 187
bladder in schistosomiasis 62
breast cancer 185, 186
breast fibroadenoma 11
chondrosarcoma 141
enchondroma 144
gall bladder 82
intraosseous lipoma 146
ivory osteoma 96
ligamentous insertion 119
liver lesions 40
liver metastases 52
lung 7, 8, 11, 20
mammography 185, 186
microcalcification in breast cancer
185, 186
myositis ossificans progressiva
123
obstructing gallstone 41
optic drusen 91
ovarian dermoid cysts 84
peritoneal 167
pleural 15
pleural pseudotumour 11
popcorn of lymph nodes 25
scleroderma 152
spleen 25
testicular microlithiasis 73
tumoral calcinosis 121
ureters in schistosomiasis 62
vascular 138
calvaria, wormian bones 168
CalvKummelVerneuil disease
154
Candida 63, 79
Caplans syndrome 6
capsule endoscopy, Crohns disease
53
cardiac granulomas 22
cardiac sarcoid 22
cardiomegaly, pulmonary arterial
hypertension 16
cardiothoracic ratio
pleural pseudotumour 11
pulmonary oedema due to heart
failure 29
Carolis disease 80
caroticocavernous fistula 103
carpal tunnel syndrome 150
cavernoma 102
cavernous haemangioma 71
cavernous sinus, caroticocavernous
fistula 103
central nervous system (CNS)
tumours 89
central pontine myelinolysis 105
cerebral abscess 90
cerebral anoxia, global 114
cerebral hemispheres, schizencephaly
169
cerebral injury, global 114, 166
cerebrovascular accident 33
cervical ribs, bilateral 28
cervical spine 120
Charcot joint 138
chemotherapy, nephroblastoma
174
chest wall
abnormalities 31
lipoma 9
chocolate cyst 83
cholangitis 80
cholecystectomy, porcelain
gallbladder 82
chondroblastoma 133
chondrocalcinosis 50
chondrosarcoma 141
cigarette smoking, asbestos exposure
15
circumferential resection margin
(CRM) 52
cirrhosis risk with haemochromatosis
50
Claudes syndrome 100
cleidocranial dysostosis 127
multiple wormian bones 168
coal workers
progressive massive fibrosis 7
rheumatoid arthritis 6
coarctation of the aorta 32
Codmans triangle 125
coeliac disease 44, 69
colectomy 49
colloid cyst 89
colon
adenocarcinoma 65
metastases 61
pneumatosis 66
polyps 49
strictures 65
vascular ectasia 39
colorectal carcinoma 52
347
General Index
ductal carcinoma in situ (DCIS)
186
duodenal atresia 44, 183
dwarfism, thanatophoric 161
dyspnoea
Langerhans cell histocytosis 27
left upper lobe tumour with
lymphangitis carcinomatosa 12
right sided bulla 35
Echino co ccus granulo sus 40
EhlersDanlos syndrome 132
Eisenmengers syndrome 16
Ellisvan Creveld syndrome 177
embolization, arteriovenous
malformations 33
emphysematous pyelitis 63
emphysematous pyelonephritis 63
encephalitis, herpes simplex virus
113
enchondroma 144
endometrioma 83
endometriosis 81, 83
endoscopic retrograde
cholangiopancreatography (ERCP)
annular pancreas 44
primary sclerosing cholangitis
45
endotracheal tube position 14
enlarged vestibular aqueduct
syndrome 86
eosinophilic granuloma 154, 158
eosinophils, pulmonary infiltration
21
ependymoma 89, 180
epidermoid cyst 94
epilepsy
haemoangioblastoma 104
tuberous sclerosis 101
Erlenmeyer flask deformity 119,
140, 178,
Escherichia co li, emphysematous
pyelitis 63
Ewings sarcoma 125
extra-corporeal membrane
oxygenation (ECMO) 164
extrinsic allergic alveolitis (EAA) 17
eyes
optic drusen 91
thyroid ophthalmopathy 88
18 fluoro-2-deoxyglucose (FDG)
24
fallen fragment sign 95
Fallots tetralogy 181
familial adenomatous polyposis
(FAP) 49
feline oesophagus 38
femoral epiphysis, slipped upper
117
femoral head
avascular necrosis 117, 135, 139
congenital multicentric ossification
135
348
femur
congenital pseudarthrosis 127
parosteal osteosarcoma 136
fibrodysplasia ossificans progressiva
123
fibromuscular dysplasia 58
fibrous dysplasia 149
figure of 3 sign 32
fine needle aspiration (FNA) 185
fistulae, Crohns disease 53
fluorosis 119, 140, 157
focal nodular hyperplasia (FNH),
hepatic 85
Fongs disease 128
fontanelle, tense 162
football sign 75, 167
fracture, slipped upper femoral
epiphysis 117
frontal sinus osteoma 96
fungal infections
Candida 63, 79
Pneumo cystis carinii pneumonia
37
see also allergic bronchopulmonary
aspergillosis (ABPA); Aspergillus
gadolinium BOPTA 85
gallbladder, porcelain 82
gallbladder carcinoma 82
gallstone ileus 41, 47
gallstones
annular pancreas association 44
Crohns disease 53
ectopic 41
pancreatitis 72
Gardners syndrome 44, 49
gastric adenoma 49
gastric carcinoma, linitis plastica
76
gastric leiomyoma 64
gastric lipoma 64
gastric varices 42
gastritis, erosive 54
Gastrograffin 173
gastrointestinal mucosa, cobblestone
53
gastro-oesophageal reflux 38
gastro-oesophageal sphincter,
pneumatic dilatation 57
Gauchers disease 119, 178
germ cell tumours 92
giant cell tumour 115, 133, 134
glioblastoma multiforme, butterfly
110
glomus jugulotympanicum tumour
108
gluten-free diet 69
gluten-sensitive enteropathy 69
gouty arthropathy 143
granulomatous disease
Crohns disease 53
Langerhans cell histiocytosis
27
Wegeners granulomatosis 5
grey matter
basal ganglia density 166
heterotopic 169
groin, hernial orifices 47
ground glass density lesion 149
gynaecomastia 140, 189
haemangioblastoma 104, 180
haemangioma 129, 137
haemochromatosis 50
haemoptysis, cystic fibrosis 36
haemosiderosis, pulmonary 23
hair on end sign 129, 155
hearing loss
acoustic neuroma 94
enlarged vestibular aqueduct
syndrome 86
glomus jugulotympanicum tumour
108
heart failure 29
hepatic abscess 80
hepatic adenoma 85
hepatocellular carcinoma
focal nodular hyperplasia
differential diagnosis 85
risk with haemochromatosis 50
hepatocytes, focal nodular
hyperplasia 85
herpes oesophagitis 79
herpes simplex virus (HSV)
encephalitis 113
high resolution computed
tomography (HRCT)
interstitial lung disease 17
primary tuberculosis 2
pulmonary sarcoidosis 1
hip joint, primary tuberculosis 2
Hirschsprungs disease 173
Histo plasma capsulatum
(histoplasmosis) 25
HIV infection
oesophagitis 79
Pneumo cystis carinii pneumonia
37
horizontal meniscal tear 159
humeral head, avascular necrosis 6,
18, 53, 65
Hurlers syndrome 184
hyaline membrane disease (HMD)
165, 170
hydatid disease 40
hydrocephalus 106, 180
hydronephrosis
horseshoe kidney 51
posterior urethral valves 172
renal obstruction 68
hypercalcaemia, pancreatitis 72
hyperparathyroidism 152, 160
renal medullary nephrocalcinosis
43
hypertension
nephroblastoma 174
neurofibromatosis 58
systemic 58
General Index
hypertrophic pulmonary
osteoarthropathy (HPOA) 36,
157
hypothyroidism, multiple wormian
bones 168
hypoxic-ischaemic injury 163
low-density basal ganglia 166
hysterectomy, adenomyosis 81
ileum, jejunalization 69
iliac horns, bilateral posterior 128
immunocompromised patients,
oesophagitis 79
imperforate anus 44, 173
infantile cortical hyperostosis 175
infections
pancreatitis 72
renal scarring 68
see also fungal infections
infertility
adenomyosis 81
endometrioma 83
inflammatory bowel disease
primary sclerosing cholangitis 45
see also Crohns disease; ulcerative
colitis
inflammatory malignancy 188
inguinal hernia 47
intracranial pressure, raised 162
intraosseous lipoma 146
intraperitoneal gas, free 75
intussusception, coeliac disease 69
invasive ductal carcinoma (IDC) of
breast 185, 186
iron overload 50
ivory osteoma 96
ivory vertebra sign 137
Jaccouds arthritis 132
jejunum folds 69
joints
primary tuberculosis 2
see also knee joint
juvenile pilocytic astrocytoma 104,
180
juvenile recurrent parotitis 87
Kerley B lines 12
kidneys
horseshoe 51
medullary sponge 43
multicystic dysplastic 172
partial duplex 78
Wilms tumour 51, 174
Klebsiella, emphysematous pyelitis
63
Kleins lines 117
knee joint
osteochondritis dissecans 131
tumoral calcinosis 121
knee instability 159
Kupffer cells, focal nodular
hyperplasia 85
lymphadenopathy
primary tuberculosis 2
pulmonary sarcoidosis 1
lymphangioleiomyomatosis 27
lymphangitis carcinomatosa, with left
upper lobe tumour 12
lymphoma 110, 140
osteoblastic response 137
recurrence following amputation
118
staging 24
Madelung deformity 147, 153
see also pseudo-Madelung
deformity
Maffucis syndrome 144
magnetic resonance angiography
(MRA), coarctation of the aorta
32
magnetic resonance
cholangiopancreatography
(MRCP)
annular pancreas 44
primary sclerosing cholangitis
45
magnetic resonance imaging (MRI),
cardiac 30
malabsorption, coeliac disease 69
malignant mesothelioma 3, 15
mammography 185, 186
benign breast cysts 187
calcifications 185, 186, 190
gynaecomastia 189
invasive lobular carcinoma 191
marble bone disease 119
mastectomy, previous breast cancer
31
mastocytosis 137, 140
McCuneAlbright syndrome 149
mebendazole, hydatid disease 40
meconium aspiration syndrome
170
meconium ileus 36, 173
meconium peritonitis 167
mediastinal mass
bronchogenic cyst 13
thoracic aortic aneurysm 10
medullary sponge kidney 43
medulloblastoma 104, 180
mega-oesophagus 57
melorheostosis 122
meningioma 89, 94
meningitis, chemical 112
meniscus sign 40
meniscus, tears 159
mesenteric angiography,
angiodysplasia association 39
mesenteric desmoid tumour, with
familial adenomatous polyposis
(FAP) 49
mesenteric ischaemia 59
mesenteric metastases 61
mesentery, tumour spread 61
349
General Index
metacarpals
head flattening 50
idiopathic shortening of 4th 147
metastases
adrenal adenoma differentiation
67
breast cancer 115, 185
bronchogenic carcinoma 24
colonic 61
colorectal carcinoma 52
drop 180
lung 8
nephroblastoma 174
osteoblastic 137
pelvic 115
prostate carcinoma 140
pulmonary 130
sclerotic 122
sclerotic bone from breast cancer
31, 137, 140
superscan 156
metastatic calcinosis 20
Meyers dysplasia 135
microcolon 173
microlithiasis, testicular 73
midbrain infarction 100
middle cerebral artery (MCA)
aneurysm 114
infarct 113
miliary nodules 25
MISME syndrome 94
mitral valve disease 23
mitral valvotomy 23
Morquios syndrome 120, 135,
184,
Moulage sign 69
mucocele, sphenoid sinus 109
mucopolysaccharidoses 184
multiple endocrine neoplasia (MEN)
108
multiple epiphyseal dysplasia 135
multiple sclerosis 97
myelofibrosis 140
myocardial fibrosis, cardiac sarcoid
22
myometrial hyperplasia 81
myositis ossificans 121
progressiva 123
nailpatella syndrome 128
nasal region, Wegeners
granulomatosis 5
necrotizing enterocolitis 167
neonates
duodenal atresia 183
meconium aspiration syndrome
170
meconium ileus 173
see also prematurity
neoterminal ileum, Crohns disease
53
nephroblastoma 174
nephrocalcinosis, renal medullary
43
350
neuroblastoma 174
neurofibroma 111
mediastinal mass 10
neurofibromatosis 127
angiomyolipoma 48
CXR changes 27
hypertension 58
neurofibromatosis type 1 111, 127
optic glioma 99
skin nodules 8
neurofibromatosis type 2 94
neurogenic bladder 60
neuronal migration, congenital
anomalies 169
neuropathic foot, diabetic 138
non accidental injury (NAI) 175,
179
oblique meniscal tear 159
odontogenic keratocyst 95
odontoid peg 120
oesophageal atresia, congenital with
tracheo-oesophageal fistula 171
oesophageal cancer 34
oesophageal rupture 34
oesophageal stents 34
oesophageal strictures 38
oesophageal tumour, with left lower
lobe collapse and cavitating
pulmonary metastases 14
oesophageal varices 42
erosive gastritis 54
oesophagitis 79
oesophagus
achalasia 57
feline 38
leiomyoma 55
oligohydramnios, posterior urethral
valves 172
Olliers disease 144
onion peel sign 40
opsoclonus, neuroblastoma 174
optic chiasm 99
compression 106
optic drusen 91
optic nerve glioma 99
oropharyngeal candidiasis 79
OslerWeberRendu syndrome 33
multiple haemangiomas 71
osteitis condensans ilii 116
osteoarthropathy
Crohns disease 53
hypertrophic 36, 157
osteochondritis dissecans 131
osteochondroma 130
osteochondromatosis, synovial 121,
135
osteochondrosis, vertebral 154
osteofibrous dysplasia 149
osteogenesis imperfecta 127, 161,
179
multiple wormian bones 168
osteoid osteoma 134, 148
osteomalacia 126, 176
osteo-onychodysplasia 128
osteopenia 168, 176
osteopetrosis 119, 140, 145
osteopoikilosis 122
osteosarcoma 125, 134
conventional 136
lung metastases 8
parosteal 136
osteosclerosis 119, 140
diffuse 155
ovarian cancer 61
ovarian dermoid cysts 84
pachydermoperiostosis 157
pachygyria 169
Pagets disease 137, 140
pancreas
annular 44, 183
pseudocyst formation 72
pancreatic insufficiency, cystic
fibrosis 36
pancreatitis 72
panda sign 1
paranasal sinus osteoma 96
parotitis, juvenile recurrent 87
parrot beak tear
meniscal 159
patent ductus arteriosus 32
pectoral muscle atrophy/absence
31
pelvic haematoma 70
pelvic overlap sign 46
peptic stricture feline oesophagus
38
percutaneous valve balloon dilatation
23
pericarditis, histoplasmosis 25
peritoneal calcification 167
periventricular leukomalacia 166
PeutzJeghers disease 49
phakomatoses 101
pilocytic astrocytoma 104
pineal germinoma 92
pituitary macroadenoma 106
pleural calcification, asbestos
exposure 15
pleural effusions
asbestos exposure 15
meconium aspiration syndrome
170
primary tuberculosis 2
pulmonary oedema due to heart
failure 29
pleural fluid, oblique fissure 11
pleural lesions, chest wall lipoma
9
pleural plaques
asbestos exposure 15
malignant mesothelioma 3
pleural pseudotumour 11
pneumatocele, Pneumo cystis carinii
pneumonia 37
pneumatosis
colon 66
General Index
pneumatosis (co ntinued)
cystoides intestinalis 66
intestinalis 65, 167
pneumobilia 41
pneumoconiosis 6, 7
Pneumo cystis carinii pneumonia
(PCP) 37
pneumomediastinum 34, 165
meconium aspiration syndrome
170
pneumonia, aspiration 171
pneumoperitoneum 34, 75
necrotizing enterocolitis 167
pneumothorax 31
bulla differential diagnosis 35
cystic fibrosis 36
endometrioma 83
Langerhans cell histiocytosis 27
meconium aspiration syndrome
170
Pneumo cystis carinii pneumonia
37
positive pressure ventilation
complication 165
polycystic kidney disease 48
polydactyly 177
polyhydramnios, annular pancreas
44
polymicrogyria 169
portal hypertension, oesophageal
varices 42
positive pressure ventilation 165
positron emission tomography
(PET), metastatic bronchogenic
carcinoma 24
posterior cruciate ligament 159
double PCL sign 159
posterior inferior cerebellar artery
infarction 100
posterior urethral valves 172
Potts disease 142
prematurity
hyaline membrane disease 165,
170
necrotizing enterocolitis 167
primary sclerosing cholangitis 45
primitive neuroectodermal tumour
(PNET) 180
progressive massive fibrosis 7
prostate carcinoma, metastases 140
Pro teus, emphysematous pyelitis 63
prune belly, posterior urethral valves
172
pseudodiverticulosis, intramural 38
pseudohyperparathyroidism 147
pseudo-Madelung deformity 130,
153
Pseudo mo nas, emphysematous
pyelitis 63
pseudoureteroceles 56
psoas abscess 142
psoriasis 116
psoriatic arthropathy 143, 152
pulmonary arterial hypertension 16
pulmonary arteriovenous
malformation 33
pulmonary asbestosis 3, 15
pulmonary embolus 31
pulmonary fibrosis
drug-induced 18
lower zone 15, 17
upper zone 15, 17, 18
pulmonary haemosiderosis 23
pulmonary interstitial emphysema
(PIE) 165
pulmonary malignancy
asbestosis 15
systemic sclerosis 17
pulmonary metastases, cavitating
14
pulmonary nodules
follow-up 6
mitral valve disease 23
oesophageal tumour 14
rheumatoid lung 6
sarcoidosis 1
pulmonary oedema 31
heart failure 29
pulmonary opacity
barium aspiration 20
ground glass 29
left upper lobe tumour with
lymphangitis carcinomatosa 12
lung lobe collapse 14
metastatic calcinosis 20
pleural pseudotumour 11
pulmonary sarcoidosis 1
pulmonary venous hypertension
mitral valve disease 23
pulmonary oedema due to heart
failure 29
pyelitis, emphysematous 63
pyeloureteritis cystica 77
pyknodysostosis 119, 168
Pyles disease 119, 178
Rathke cleft cyst 106
Raynauds phenomenon 17
thoracic outlet syndrome 28
rectum
stented tumour with calcified liver
metastases 52
ulcerative colitis 65
Reiters syndrome 116, 143
renal adenocarcinoma 51
renal artery stenosis 58
renal ectopia, crossed fused 68
renal lesions, fat 48
renal medullary nephrocalcinosis 43
renal obstruction, hydronephrosis
68
renal osteodystrophy 119, 140
renal papillary necrosis 78
renal scarring, infections 68
renal stones, horseshoe kidney 51
renal tuberculosis with
autonephrectomy 74
renal tubular acidosis 43
reninangiotensin system,
overactivity 58
respiratory distress, meconium
aspiration syndrome 170
reversal sign 114, 163
rheumatic heart disease 23
rheumatoid arthritis 120, 143
rheumatoid factor 17
rheumatoid lung 6
rheumatologic syndromes,
histoplasmosis 25
ribs
bilateral cervical 28
exostoses 130
lesions 9
notching 32
rickets 168, 175, 176
right ventricular hypertrophy, mitral
valve disease 23
Rigler sign 75, 167
Riglers triad 41
Rokitansky nodule 84
S sign of Golden 14
sacral agenesis 173
sacroiliac joint disease
Crohns disease 53
ulcerative colitis 65
sacroiliac joint fusion 139
sacroiliitis 116, 143
sandwich vertebrae 140
sarcoidosis
cardiac sarcoid 22
pulmonary 1
schistosomiasis 62
schizencephaly 169
scleroderma 132, 152
sclerosis
Charcot joint 138
diffuse 119
septal thickening, interlobular
29
sialectasis, juvenile punctate 87
sickle cell disease 129, 140, 155
siderosis, transfusion 50
sigmoid colon, displacement 84
sigmoid volvulus 46
silicosis 18
simple bone cyst 115
Sjgrens syndrome 87
skin folds, lung edge artefact 35
skin nodules, neurofibromatosis type
1 8
slipped upper femoral epiphysis
(SUFE) 117
small bowel
adenoma 49
ischaemia 59
loop dilatation 69
strictures 59
thickening in Crohns disease 53
small bowel obstruction 41
adhesions 47
mechanical 41, 47
351
General Index
sphenoid sinus mucocele 109
spleen, calcification 25
spondyloarthropathy 143
spondylitis, tuberculous 142
Staphylo co ccus aureus, Brodies
abscess 134
steroid use
avascular necrosis of femoral head
139
avascular necrosis of humeral head
6, 18, 53, 65
cerebral abscess 90
Meyers dysplasia 135
rheumatoid disease 6
stillbirth 161
string of beads sign 47
subarachnoid haemorrhage 114
subclavian artery stenosis 19
subclavian steal syndrome 19
subependymal hamartomas 101
subependymal nodules 169
sulphur colloid scans, focal nodular
hyperplasia 85
superior mesenteric vein thrombosis
59
superscan, metastases 156
surfactant therapy 165
SwyerJames syndrome 31
syndactyly 177
syndesmophytes 18, 116
synovial osteochondromatosis 121,
135
systemic lupus erythematosus (SLE)
132
systemic sclerosis 17
teeth, ovarian dermoid 84
tension pneumothorax
intrapulmonary bronchogenic cyst
13
positive pressure ventilation
complication 165
terminal ileum
Crohns disease 53
ulcerative colitis 65
testicular microlithiasis 73
tetralogy of Fallot 181
thalassemia 119, 178
major 124, 129
thanatophoric dysplasia 161
thoracic aortic aneurysm 10
thoracic outlet syndrome 28
thyroid acropachy 157
thyroid cancer, miliary metastases 4
thyroid ophthalmopathy 88
TNM staging, colorectal carcinoma
52
total mesorectal excision (TME)
procedure 52
toxic megacolon, perforation 65
tracheo-oesophageal atresia 44
352